THE 



DIAGNOSIS 



OF 



DISEASES OF WOMEN. 



A TREATISE FOR STUDENTS AND PRACTITIONERS. 



BY 

PALMER FINDLEY, B.S., M.D., 

INSTRUCTOR IN OBSTETRICS AND GYNECOLOGY, RUSH MEDICAL COLLEGE IN AFFILIATION 

"WITH THE UNIVERSITY OF CHICAGO ; ASSISTANT ATTENDING GYNECOLOGIST 

TO THE PRESBYTERIAN HOSPITAL, CHICAGO. 



ILLUSTRATED WITH 210 ENGRAVINGS IN THE TEXT AND 45 PLATES 
IN COLORS AND MONOCHROME. 




LEA BROTHERS & CO., 

PHILADELPHIA AND NEW YORK 
19 03. 



THE LIBRARY OF 
CONGRESS, 

Two Copies Received 

SWAY 5 1903 

Copyright Emrv 

copy a, 







Entered according to the Act of Congress, in the year 1903, by 

LEA BROTHERS & CO., 
In the Office of the Librarian of Congress. All rights reserved. 



/P 



DORNAN, PRINTER. 



IN 

FILIAL AFFECTION 
FOR 

DAVID FINDLEY, M. D., 

AND AS A TRIBUTE TO THE ACHIEVE1IENTS 
IN GYNECOLOGY AND OBSTETRICS 

OF 

J. CLARENCE WEBSTER, A.M., M.D., F.R.S.E., F.R.C.P. 

TH IS BOOK IS 
DEDICATED. 



PREFACE. 



It has been the endeavor of the author to write a work on the 
Diagnosis of Diseases of AVomen that will be equally adapted to 
the needs of student and practitioner, and in line with the most 
modern views. The recognition of the pathology of the pelvic 
organs in large measure constitutes a diagnosis. Because of this 
fundamental fact the author has deemed it desirable to incorporate 
a thorough discussion of the morbid anatorny, both macroscopic and 
microscopic, and to point out its clinical indications. Special stress 
has been placed upon the microscopic diagnosis of the various 
lesions, not alone on account of its scientific interest, but also, and 
more particularly, because of its great clinical importance. Without 
the microscope a diagnosis is not always possible. 

Medical literature in the English language has not hitherto 
included a work on this subject. In the effort to supply this 
desideratum the author has aimed to satisfy the requirements of 
those who have felt the need of more comprehensive and prac- 
tical information than can be given in the general text-books on 
gynecology. It is hoped that this work will be serviceable to 
those who do not have access to foreign literature. 

The author desires to express appreciation of the services rendered 
in the writing of the book. Dr. D. P. Johnson gave invaluable 
assistance in the critical reading of the manuscript; Dr. Charles 
G. Farnum in the correction of the proof; Miss Mamie Findley 
and Dr. Carl AVahrer in the production of illustrations. Indebted- 
ness is also acknowledged to "Veto's Handbuch fur Gynakoloc/ie, 



vi PREFACE. 

Winter's Gyndkologische Biagnostik, Webster's Ectopic Pregnancy, 
Cullen's Cancer of the Uterus, Kelly's Operative Gynecology, and 
Dudley's Gynecology. The author furthermore desires to express 
appreciation of his very cordial relations with the publishers, 
which have at all times been most gratifying. 

PALMEK FINDLEY. 

100 State Street, Chicago, 1903. 



CONTENTS 



PART I. 



GENERAL DIAGNOSIS. 



CHAPTER I. 



The Clinical History 



A Plea for an Early Diagnosis 
Form of Case Record . 

Address . 

Age 

Occupation 

Nationality- 
Social State 

Number of Children and Miscar 

Family History .... 

Previous Illnesses .... 

Present Complaints 

Menstrual History .... 

Hemorrhage from the Genital Tract 

Menstruation 

Anatomy of Menstruation 

Menstruating Fallopian Tube 
Uterine Hemorrhage 

Systemic Causes 

Local Causes . 
Amenorrhoea 

General Causes 

Local Causes . 

Menstrual Molimena 
Dysmenorrhoea 

Idiopathic (Primary) 

Secondary 

Membranous . 
Sterility in Women 

General Causes 

Local Causes . 



PAGE 

17 

17 
19 
21 
21 
22 
22 
22 
22 
23 
23 
23 
23 
23 
24 
26 
28 
28 
29 
29 
34 
34 
35 
36 
36 
37 
37 
38 
38 
40 
41 



Vlll 



CONTENTS. 



Menopause . 

Factors Influencing 
Leucorrhoea . 

Normal Secretions . 

In Infants 

In Virgins 

In Period of Sexual Maturity 

In Old Women 



PAGE 

44 
44 

45 
45 
45 
45 
46 
46 



CHAPTER II. 

Physical Examination 



Preliminary Measures 



48 
48 



CHAPTER III. 
External Abdominal Examination. Inspection of the Abdomen . 51 



CHAPTER IV. 

Palpation of the Abdomen 



52 



CHAPTER V. 

Percussion of the Abdomen 



55 



CHAPTER VI. 

Auscultation and Mensuration of the Abdomen 



56 



CHAPTER VIL 



Examination of the External Genitals 



Digital Examination of the Internal Genitals 
Vagina .... 
Choice of Hand 
One or Two Fingers Used ? 
Bimanual Examination . 
Abdomino-vaginal Examination . 
Examination under Narcosis . 
Digital Examination of the Rectum 
Abdomino-rectal Examination 
Abdomino-vagino-rectal Examination 
Digital Examination of the Bladder 
Pelvimetry 



57 

57 
57 
59 
60 
62 
62 
66 
66 
68 
69 
69 
70 



CONTENTS. 



IX 



CHAPTER VIII. 

Vaginal Speculum 



page 
71 



CHAPTER IX. 

Vulsella 

CHAPTER X. 

Uterine Dilators 



Preliminary Measures 
Indications . 
Dangers Involved . 



CHAPTER XL 

Uterine Sound 



82 

82 
82 
84 



In Diagnosis 

Contraindications 

Technic 



CHAPTER XII. 

Uterine Curette 



86 

86 



CHAPTER XIII. 

Microscopic Examination of Scrapings and Excised Pieces . 91 

Removal of Scrapings • . . . .91 

Test Excision from the Cervix ......... 92 

Test Curettage of the Uterus 92 

Frozen Sections ............ 92 

Fixing the Specimens ........... 95 

Hardening and Embedding . . . . . . . . . .95 

Method of Staining and Mounting 97 

Inspection of the Uterus after Removal 99 



CHAPTER XIV. 

Exploratory Punctures and Incisions 



100 



CONTENTS. 



PART II 



SPECIAL DIAGNOSIS. 



CHAPTEK XV. 

The Diagnosis of Pregnancy 

First Trimester ..... 
I. Subjective Signs 

1. Cessation of Menstruation . 

2. Morning Sickness 

3. Salivation .... 

4. Nervous Phenomena . 

5. Irritable Bladder 
II. Objective Signs 

1. Mammary Glands 

2. Discoloration of Vulva and Vagina 

3. Softening of Cervix . 

4. Lower Uterine Segment 

5. Leucorrhoea 

6. Change in the Position, Size, Fori 
Second Trimester 

I. Subjective Signs 
II. Objective Signs 



6. 



Active Foetal Movements . 
Passive Foetal Movements . 
Direct Palpation of the Foetus 
Intermittent Uterine Contractions 
Auscultation . 
Foetal Heart Tones . 
Foetal Souffle . 
Placental Souffle 
Kate of Growth of Uterus . 
7. Changes in Position, Size, Form, 

Third Trimester 

I. Subjective Signs ... 
II. Objective Signs 
Diagnosis of the Life or Death of the Foetus 
Diagnosis of the Time of Pregnancy and Prediction 
Diagnosis of Multiple Pregnancy . 
Diagnosis of the Causes of Hemorrhage Occurring 
Diagnosis of Abortion .... 
Anatomical Diagnosis of Pregnancy 



m, and Consistency of Uterus 



and 



Consistency of Uterus 



of Date of Confinement 
during Pregnancy . 



PAGE 

101 

101 
101 
101 
103 
103 
104 
104 
104 
104 
104 
104 
106 
106 
107 
107 
107 
107 
107 
107 
108 
108 
109 
109 
109 
109 
109 
110 
110 
110 
110 
111 
112 
113 
113 
115 
116 



CHAPTER XVI. 

Microscopic Diagnosis of Expelled Membranes from the Uterus . 120 



CONTENTS. 



XI 



CHAPTER XVII. 



The Diagnosis of Ectopic Pregnancy 



Etiology ..... 
Classification .... 

Retrogressive Changes in the Foetus 
Anatomical Changes in the Tube . 
Clinical Diagnosis 

Subjective Signs 

Objective Signs 
Differential Diagnosis . 



PAGE 

122 

122 
123 
129 
130 
132 
133 
133 
138 



CHAPTER XVIII. 



142 



X71AWJNUS1S V* niilAHFUKJl ^ 


LU-LrJi; .... -Lt^ 


Synonyms 


142 


History 


142 


Etiology ........ 


142 


Microscopic Examination ..... 


..... 146 


Malignant Degeneration ..... 


151 


Diagnosis ........ 


154 



CHAPTER XIX. 

Diagnosis of Chorio-epithelioma Malignum 



Etiology 

Diagnosis 

Macroscopic Appearance 



160 

161 
161 
162 



CHAPTER XX. 



Diagnosis of Malformations of the Uterus 



Uterus Deficiens . 
Uterus Rudimentarius . 
Uterus Fcetalis 
Uterus Unicornis . 
Uterus Septus (Bilocularis) 
Uterus Bicornis 
Uterus Didelphys . 
Uterus Accessorius 



163 

163 
163 
164 
166 
168 
168 
169 
169 



CHAPTER XXI. 

Diagnosis of Malposition of Uterus and its Neighboring Organs 



Pathological Mobility of the Uterus 
Pathological Fixation of the Uterus 



171 

171 
171 



Xll 



CONTENTS. 



Anteposition 

Retroposition 

Lateroposition 

Elevatio Uteri 

Torsion of the Uterus 

Prolapsus Uteri . 

Inversion of the Uterus 

Anteversion of the Uterus 

Anteflexion of the Uterus 

Retroversio-fiexion of the Uterus 

Hernia of the Uterus (Hysterocele 



PAGE 

173 
173 
174 
176 
177 
178 
187 
193 
194 
195 
203 



CHAPTER XXII. 



Diagnosis of Disease 



Anomalies in Development 

Vulvitis 

Circulatory Disturbances 

Atrophy (Kraurosis Vulvse) 

New Formations . 

Ulcers .... 

Pruritus Vulvae 

Hymen 



or the Vulva 



204 

204 
206 
208 
211 
213 
217 
217 
218 



CHAPTER XXIII. 

Diagnosis of Diseases of the Vagina . . . 221 

Maldevelopments and Malformations ........ 221 

Vaginitis (Colpitis) 225 

Paravaginitis . . . . . . • . . . . . • 229 

New Formations 229 

CHAPTER XXIV. 



Clinical Classification 


1K1TJ 


!? 








235 


1. Acute Endometritis .... 






• 






235 


2. Chronic Endometritis 












236 


Anatomical Classification .... 












240 


I. Macroscopic 












240 


II. Microscopic 












241 


Diagnosis of Uterine Scrapings in Endometritis 












249 


Endocervicitis ...... 












249 


Erosions of the Cervix .... 












250 


Ulcers of the Cervix 












254 



CONTENTS. 



xm 



Tuberculosis of the Cervix 
Chronic Metritis . 



PAGE 

254 
255 



CHAPTER XXV. 



Diagnosis of Fibromyoma of the Uterus 



Etiology 
Histogenesis . 
Anatomical Diagnosis 
Microscopic Diagnosis 
Adenofibromyoma Uteri 
Degeneration of Fibroids 
Changes in the Endometrium 
Clinical Characteristics 
Clinical Diagnosis 
Differential Diagnosis 



, Myometrium, 



Tubes, and Ovaries 



256 

256 
257 
258 
262 
264 
265 
268 
268 
269 
275 



CHAPTER XXVI. 



The Diagnosis of Carcinoma of the Uterus 



Topographical Classification 
Etiology 

Anatomical Diagnosis 
Clinical Diagnosis 
Microscopic Diagnosis 
Differential Diagnosis 
Diagnosis of Extension 
Diagnosis of Recurrence 
Endothelioma 



279 

279 
279 
281 
285 
289 
296 
301 
304 
304 



CHAPTER XXVII. 

The Diagnosis of Sarcoma of the Uterus 



Etiology 

Anatomical Diagnosis 
Microscopic Diagnosis 
Clinical Diagnosis 



306 

306 
306 
307 
308 



CHAPTER XXVIII. 

The Diagnosis of Diseases of the Tubes . . . 310 

Methods of Examination .......... 310 

Anomalies in the Structure .......... 310 

Changes in the Position .......... 311 

Circulatory Disturbances 312 



XIV 



CONTENTS. 



Inflammations and Infections 

Granulomata . 

Classification of Salpingitis 

Catarrhal Salpingitis 

Salpingitis Isthmica Nodosa 

Hydrosalpinx 

Tubo-ovarian Cyst . 

Hematosalpinx 

Purulent Salpingitis 

Diagnosis of Sactosalpinx 

Differential Diagnosis of Salpingitis 

Tuberculous Salpingitis . 

Syphilis of the Fallopian Tube 

Actinomycosis of the Fallopian Tube 

Parasites of the Fallopian Tube 
New Formations of the Fallopian Tube 



CHAPTER XXIX. 



The Diagnosis of the Diseases of the Ovary 



Normal Anatomy . 
Histology .... 
Methods of Examination 
Anomalies in Development . 
Changes in Position 
Descensus Ovarii . 
Hernia ..... 
Hypertrophy 

Atrophy .... 
Parasites and Foreign Bodies 
Circulatory Disturbances 
Inflammations (Ovaritis) 

Acute Ovaritis 

Chronic Ovaritis . 

Cystic Degeneration 

Abscess .... 

Clinical Diagnosis of Ovaritis 

Differential Diagnosis 
Simple Cysts 
Infectious Granulomata 

Tuberculosis . 

Syphilis 

Actinomycosis 

Leprosy . 
New Formations 

Etiology 

Classification 

Carcinoma 



CONTENTS. 



xv 



New Formations — 
Dermoid Cysts 
Fibroma 
Myoma . 
Sarcoma 
Endothelioma 
Parovarian Cysts 

Clinical Diagnosis of New Formations 
Intraligamentary Development 
Adherent Tumors . 
Torsion of the Pedicle . 
Rupture of an Ovarian Cyst 
Leakage of an Ovarian Cyst 
Hemorrhage into the Cyst 
Suppuration of the Cyst 
Malignant Degeneration of the Cyst 
Ovarian Tumors Complicating Pregnancy 
Diagnosis of the Variety 
Fate of Ovarian Tumors 



CHAPTER XXX. 

The Diagnosis of Peritonitis 



General Peritonitis 
Tuberculous Peritonitis 
Carcinomatous Peritonitis 
Pelvic Peritonitis . 



PAGE 

365 
369 
370 
370 
371 
371 
373 
384 
385 
385 
388 
388 
388 
389 
389 
390 
390 
391 



393 

393 
395 
395 

395 



CHAPTER XXXI. 

The Diagnosis of Parametritis (Pelvic Cellulitis^ 



Definition 
Classification 
Acute Parametritis 
Chronic Parametritis . 
Differential Diagnosis . 



402 

402 
402 
403 
404 
406 



PAKT III 



DIAGNOSIS OF DISEASES OF THE URINARY SYSTEM. 
CHAPTER XXXII. 

The Diagnosis of the Diseases of the Urethra and Bladder . 409 

Anatomy 409 

Physiology 411 



XVI 



CONTENTS. 



PAGE 

Topography 411 

Natural Landmarks 412 

Methods of Examining 413 

Percussion 414 

Palpation 415 

Catheter and Sound 415 

Inspection 415 

Urethroscopy 415 

Cystoscopy 415 

Segregator .....'. 430 

Malformations and Diseases of the Urethra ....... 432 

Malformations and Diseases of the Bladder ....... 437 



CHAPTER XXXIII. 

The Diagnosis of the Diseases of the Ureters 



Anatomy 

Physiology . 

Methods of Examination 

Congenital Anomalies . 

Ureteritis 

Obstruction of 

Fistula .... 



453 

453 
453 

454 
458 
459 
461 
464 



CHAPTER XXXIV. 

The Diagnosis of the Diseases of the Kidney 



465 



Topography ........ 


. 465 


Methods of Examination ..... 


465 


Movable Kidney 


465 


Perinephritic Abscess 


. 469 


New Formations . 


.... 469 


Renal Calculi 


471 



CHAPTER XXXV. 

Diagnosis of the Causes of Too Frequent and Painful Urination . 474 

CHAPTER XXXVI. 

Diagnosis of the Causes of Incontinence and Retention of Urine . 476 



GYNECOLOGICAL DIAGNOSIS 



PART I. 
GENERAL DIAGNOSIS. 



CHAPTEE I. 

THE CLINICAL HISTORY. 

In the diagnosis of diseases peculiar to women we have not only 
to recognize the disorders as found in the genitalia, their character 
and extent, but we must take under consideration associated lesions 
and functional disturbances in all parts of the body. To this end 
a systematic general examination should precede the local exami- 
nation, and careful inquiry should be made into the family history 
and into the personal history relative to the social state and 
previous illnesses. 

In order to be successful in the treatment of diseases peculiar to 
women we must duly consider all conditions — physical, social, and 
moral — that influence her well-being. 



A PLEA FOR AN EARLY DIAGNOSIS. 

The importance of an early diagnosis cannot be too strongly 
emphasized. The deplorable mortality in malignant disease, the 
progressive and destructive course of pelvic infections, the remote 
results of traumatisms and displacements of the pelvic viscera 
speak more emphatically than can words for the importance of an 
early diagnosis in diseases of women. The insidious onset of many 
of the lesions, the existence of malignant growths long before 

2 



18 GENERAL DIAGNOSIS. 

giving rise to a clinical sign, speak for the uncertainty of any 
procedure looking to the early recognition of pelvic disorders. 

Physicians are too often dilatory in recognizing conditions for 
examinations and in impressing their patients with the importance 
of an immediate one when there is a suggestion of departure 
from the normal. More frequently, however, the patient is at 
fault through ignorance, indifference, sloth, and so-called modesty. 
Thus a delayed menstrual period is unheeded until the rupture of a 
tubal pregnancy ; the supposed return of the menstrual flow proves 
to be the bleeding of an inoperable cancer ; a leucorrhoeal discharge 
goes unheeded until the infection has spread to the tubes ; a pain in 
the back becomes an every-day complaint, yet awakens no suspicion 
of a uterine displacement or a new-growth. And so it is that 
lesions of the pelvic viscera go unrecognized until far advanced and 
ofttimes incurable. 

THE CLINICAL HISTORY. 

In the making of a diagnosis the first important step is the 
recording of a clinical history. A carefully recorded history has 
many advantages : it serves as a guide to a systematic examination, 
and places before the physician a detailed, logical record of the 
case for future reference. 

It is manifestly impossible to always adhere to a set form in 
case-taking. Neither is it possible to always adhere to the very 
good general rule of taking the full history at the time of the first 
examination. 

The nervous state of the patient, together with many other 
factors, may preclude the taking of a complete history at the 
time of the first consultation. But at all times certain definite 
items may be recorded, and the history completed at a subsequent 
visit. 

It is good advice given to students in text-books to begin with 
permitting the patient to recite her complaints without interruption. 
The patient becomes self-possessed, while at the same time the 
physician is given an opportunity to observe her general appearance, 
temperament, complexion, nutrition, carriage, and many other 
points bearing upon her case. After a time direct questions may 
be put to her, and as the answers are given they may be concisely 
placed on record. 



THE CLINICAL HISTORY. 19 



FORM OF CASE RECORD. 



In all text-books students are given a blank form to be filled out 
in the taking of a history. Such forms are of great service to the 
inexperienced practitioner, but for one who through long experience 
has acquired the art of case-taking they are unnecessary and ill- 
adapted. The allotted space may be inadequate to suit individual 
requirements. For myself, I prefer my letter-head, upon which 
the answers to questions can be hurriedly jotted, and to which sub- 
sequent notations can be added. This is placed in an envelope on 
which is recorded the name and address. These envelopes can be 
filed away in alphabetical order. Notes from all subsequent exam- 
inations, copies of prescriptions, correspondence with patient and 
physician can all be placed in the envelope from time to time. 
When visiting the patient the envelope can be placed in the pocket 
and referred to on the way. 

As a compromise between the elaborate printed forms and the 
blank letter-head, the following form is recommended for simplicity, 
accuracy, and liberal spacing : 



Name 


Address 


Date 


Patient of Dr. 


Address 




Age 


Occupation 


Nationality 


S. M. W. 


Para 


Miscarriages 



Events following childbirths and miscarriages 
General appearance 
Family history 
Previous illnesses 
Present complaints 



Menstrual history Menses began Type 

Quantity Duration 

Pain Menopause 



20 GENERAL DIAGNOSIS. 

Intermenstrual pain 

Leucorrhoea 

General physical findings 



Nervous system 






Cardio-vascular system 






Digestive system 






Respiratory system 






Urinary system 






Urinalysis : 






Amount in twenty-four hours 

Reaction 

Total solids 


Color 

Albumin 

Urea 


Sp. gr. 
Sugar 
Microscope 


Physical findings in pelvis and abdomen : 






Abdominal wall 
Tender on pressure 
Visceroptosis 


Swellings 





Vaginal outlet 



Vagina 



Cervix 



Uterine body 



Tubes 



THE CLINICAL HISTORY. 21 

Ovaries 

Bladder 

Rectum 

Extragenital structures 

Diagnosis 

Treatment 

Termination 

A brief discussion of the above items will be of interest. 

1. Address. The place of residence is inquired into, not only as 
a matter of business, but also to determine the possible influence of 
the environment upon the general health of the individual. Malarial 
districts, congested portions of the city, extremely warm or cold 
climates, exercise a definite influence upon the general and local 
condition of a woman. 

2. Age. The special disturbances found in the various stages of 
life — i. e., infancy, puberty, sexual maturity, climacteric and post- 
climacteric — are at once suggested when the age of the patient is 
known. 

In infancy malformations and inflammations of the lower genital 
tract are to be looked for ; tumors, displacements, and traumatisms 
seldom appear. 

At puberty malformations of the genital organs are commonly 
first noticed through failure of the menses to appear ; congenital 
displacements first cause disturbance at this time, because of the 
increase in the size of the uterus and the establishment of the men- 
strual functions ; inflammations are usually confined to the vulva, 
rarely extending above the hymen ; new formations and traumatisms 
are seldom observed. 

During the period of sexual maturity all lesions of the genital 
organs may be found. Congenital malformations may first be 
observed after marriage and in childbearing. Inflammatory 



22 GENERAL DIAGNOSIS. 

lesions, involving part or all of the genital tract, most often arise 
as the result of childbearing, specific infection, and instrumental 
and digital manipulations. New formations usually make their 
appearance in this period. Displacements and traumatisms occur 
as the result of childbearing. 

At the climacteric and postclimacteric periods all disorders have 
a special clinical significance. The possibility of malignancy should 
always be borne in mind. After seventy years of age it is unusual 
for any disorder to arise. 

3. Occupation is an important factor in the causation and aggrava- 
tion of pelvic disorders. In young girls confined in workshops the 
menstrual functions are seldom perfectly established. Poor ven- 
tilation, long working hours, heavy lifting, poor food, all exercise 
an unfavorable influence upon the development of the pelvic viscera 
and tend to aggravate existing maladies. On the other hand, 
sedentary and indolent habits are equally injurious. 

4. Nationality. The Jewish race is said to menstruate early and 
to early reach the menopause. The Caucasian race is more subject 
to carcinoma, the African to fibroids. 

5. Social State. It is well to inquire into the social state of the 
patient — to learn whether she is single, married, or a widow. An 
early understanding may forestall an embarrassing question as to 
the sexual relations, and will especially suggest possible causes for 
her complaints. For example, a recently married woman com- 
plaining of a leucorrhoea and painful urination is suspected of being 
infected. The fact that the patient is single or a widow should 
never mislead the examiner in his diagnosis ; the possibility of 
pregnancy and venereal infection must always be excluded by the 
usual methods of examination, uninfluenced by the social state of 
the patient. While the physician must be alert to these possibilities 
he should exercise great tact and caution in his inquiries. 

6. Number of Children and Miscarriages. Frequent childbearing 
and miscarriages almost certainly result in some sort of pelvic 
ailment. It is exceptional for a woman to give birth to several 
children without acquiring a pelvic disturbance. Complaints dating 
back to a childbirth or miscarriage suggest the probable finding 
of an inflammatory lesion, a displacement, or laceration. 

The condition of the bowels and bladder, the cardio-vascular, 

nervous, and respiratory systems should be carefully inquired into. 

Not infrequently a pelvic lesion is dependent upon a disorder of 



THE CLINICAL HISTORY. 23 

the abdominal or thoracic viscera. Dysmenorrhea, leucorrhcea, 
uterine hemorrhage, and sterility may be directly referred to a 
general disturbance. An excitable and overwrought nervous 
system alone may be responsible for many of the functional dis- 
orders of the pelvic viscera. Regard for the general condition of 
the patient and a due appreciation of the influence of the general 
upon local conditions will do much toward eliminating so-called 
" meddlesome gynecology." 

7. Family History. It is not probable that heredity plays an 
important role in the etiology of pelvic disorders. In tuberculosis 
and to a less degree with carcinoma the influence of heredity should 
not be underestimated ; but with the benign tumor formations, 
displacements, and malformations, heredity has little or nothing 
to do. 

8. Previous Illnesses. Acute infectious diseases, tuberculosis, and 
all chronic wasting diseases, anaemias, and long-standing lesions of 
the thoracic and abdominal viscera may both originate and aggra- 
vate disorder in the genital tract. 

9. Present Complaints. The complaints of the patient will often 
serve as a suggestion, but a diagnosis can never be based upon the 
objective signs in the absence of a physical examination. Any and 
all of the pelvic lesions may exist without subjective symptoms. 
On the other hand, there may be serious complaints on the part of 
the patient in the absence of a pelvic lesion. The familiar group 
of symptoms — hemorrhage, pain, leucorrhcea, constipation, and 
backache — are common to many altogether dissimilar lesions in the 
pelvis. We can, therefore, place but little reliance upon the com- 
plaints of the patient, but must depend in great part upon the 
physical findings. 

10. Menstrual History. So far, we have considered the patient 
from the standpoint of the general practitioner. We now come to 
consider more particularly the disorders of the genital organs. 

HEMORRHAGE FROM THE GENITAL TRACT. 

In diseases of women the most significant of all symptoms is 
hemorrhage. While not in itself diagnostic, it is of the greatest 
value as an indication for an immediate and searching physical 
examination, both general and local. Hemorrhage from the genitalia 
comes from the vulva, vagina, cervix, body of the uterus, and 



24 GENERAL DIAGNOSIS. 

occasionally from the tubes ; never from the ovary except in the 
case of a tubo-ovarian hematoma discharging its contents into the 
uterus — a most unusual event. 

From the vulva hemorrhage is the result of trauma, new forma- 
tions, ulcerations, lupus, cancroid, and rupture of varicose veins 
complicating pregnancy. The origin of the bleeding is recognized 
by direct inspection. 

From the vagina hemorrhage is the result of causes similar to 
those above enumerated. An exceptional cause lies in metastatic 
growths of syncytium (syncytioma malignum). The bleeding site 
is readily disclosed by the vaginal speculum. 

From the vaginal portion of the cervix hemorrhage follows imme- 
diately upon the delivery of the child as the result of lacerations. 
At the end of the childbearing period the most common cause of 
hemorrhage is carcinoma. Less frequent causes are sarcoma, tuber- 
culosis, and erosions. 

Before considering the morbid conditions causing bleeding from 
the uterus, let us briefly consider what may be looked upon as a 
physiological uterine hemorrhage. 

MENSTRUATION. 

No organism loses so much blood from the uterus as does 
woman. Within certain ill-defined limits this loss of blood is 
physiological ; hence it behooves us to consider first of all the char- 
acter of the menstrual act before taking up the discussion of patho- 
logical bleeding. The time of the onset of the menstrual function 
varies widely among individuals. Climate has much to do with 
determining the onset, and heredity has some influence. In this 
country Engelmann found the average age to be fourteen, in cold 
climates sixteen, and in warm climates nine years. We are all 
familiar with instances of precocious menstruation. The earliest 
case occurred in Glasgow at four days of age. Irion records a case 
at seven days, and the literature abounds in cases a few weeks and 
months of age. In nearly all these cases the genitalia were abnor- 
mally developed ; there was hair on the pubis, and the breasts were 
often enlarged. It is not probable that menstruation could occur 
without premature development of the menstrual organs, and where 
this development is not found the hemorrhage should not be 
regarded as catamenial unless it recurs at monthly intervals. The 



PLATE I. 



E&w;*,#\^ ••• 












fells ^*® ll 







■ ..-.■. 






'"J 












^^ya 



Anatomy of the Menstruating Uterus. 



THE CLINICAL HISTORY. 25 

mother will bring to the physician a napkin marked by a red stain, 
and will ask if it be possible that her child is menstruating. Such 
stains may be blood from a vulvovaginitis or urethritis, but are 
more often deposits of red urates or uric acid. 

As to the frequency of the menstrual period, it is often stated 
that the normal type is twenty-eight days. But women are rarely 
so regular ; there is usually a variation of one or more days. 
Regularity in the menstrual functions adds neither strength nor 
grace. Women menstruate at long or short intervals without ill- 
effect, providing the quantity of blood lost does not materially lessen 
their strength. 

The average quantity of menstrual blood lost in a single period 
is estimated at six to eight ounces — the minimum two and the 
maximum ten. Obviously what may be regarded as a normal 
quantity for one may be abnormal for another. A plethoric, well- 
nourished woman may menstruate freely for eight days without 
harm, while the same loss of blood in an anaemic individual might 
seriously undermine her strength. 

It is impractical to collect the menstrual blood. To estimate the 
amount of blood lost, the number of napkins soiled are counted. 
No exact information is gained by this procedure, because the size 
and quality of the napkins vary, and one woman will tolerate an 
over-saturated napkin, while another will scarcely permit staining. 
However, we have no better means at our command, and by esti- 
mating the usual number at fourteen napkins in the entire period 
we arrive at a fair estimate. 



DESCRIPTION OF PLATE I. 

Fig. 1 represents a specimen removed twenty-six hours after the onset of the menstrual flow. 
It corresponds to the first stage of Gebhard. The capillaries, which are rarely visible in the 
intermenstrual period of the normal uterus, are here shown to be widely dilated; a sero- 
sanguineous exudate permeates the stroma, widening the intercellular spaces ; these changes 
are more marked near the surface. The glands are not affected, and the surface epithelium is 
intact and apparently normal. 

Fig. 2 represents a specimen removed on the third day of menstruation, and corresponds to 
the second stage of Gebhard. The " subepithelial hsematoma " is well-marked ; the surface 
epithelium is lifted from its bed by the blood beneath ; here and there the blood has burst 
through the epithelial covering and has carried away with it small bits of epithelium. Fatty 
degeneration of the mucosa is not in evidence. 

Fig. 3 represents a specimen removed the day following the cessation of the menstrual flow ; 
it corresponds to the third stage of Gebhard. The bloodvessels are less engorged than in the 
preceding specimen ; the blood extravasated into the stroma is less in amount and does not 
give the appearance of fresh blood. The surface epithelium is intact and closely adherent to 
the stroma. 



26 GENERAL DIAGNOSIS. 

Anatomy of the Menstruating Uterus. 

Kundrat and Engelmann were tlie first to record anatomical 
observations on the menstruating uterus. These observations were 
made on cadavers in which the endometrium of the uterine body 
had undergone fatty degeneration and the surface epithelium was 
exfoliated. 

Later, Williams made postmortem examinations of twelve men- 
struating uteri. Nine of the twelve cases died of acute infectious 
diseases. He found fatty degeneration of the mucosa of the uterine 
body, as did Kundrat and Engelmann, and stated that the entire 
mucosa down to the musculature was exfoliated, that following 
menstruation the mucosa was regenerated from the musculature. 

Leopold recognized the observations of Kundrat, Engelmann, 
and Williams as faulty, in that the changes in the endometrium as 
described by them might result from the acute infectious and 
chronic wasting diseases which were the causes of death. He care- 
fully excluded all such, selecting those of normal menstrual type. 
He failed to observe fatty degeneration of the mucosa, but agreed 
that the surface epithelium was shed in the menstrual process. He 
does not state how long after death the sections were made, or the 
method of preparing the specimens. Within a few hours, certainly 
within twenty-four hours, after death or hysterectomy the surface 
epithelium undergoes degenerative changes and may be wholly lack- 
ing in microscopic sections. 

It was Moricke who first excluded the possibility of postmortem 
and postoperative changes in the uterus by examining scrapings 
from the normal menstruating uterus. He curetted and made 
microscopic examinations of forty-five menstruating uteri in all 
stages of menstruation. In every instance the surface epithelium 
was found intact. In two additional cases Lohlein reported 
similar findings. 

Westphalen also made a series of examinations of scrapings of 
the mucosa during the various stages of menstruation. In every 
case where the mucosa was normal the entire membrane was well 
preserved ; in morbid conditions of the mucosa part or all of the 
surface epithelium was shed. Mandle confirmed these findings. 

The most elaborate observations were carried out by Gebhard in 
Berlin. He not only examined scrapings, but also sections of 
uteri removed during the menstrual period for lesions not involv- 



THE CLINICAL HISTORY. 27 

ing the endometrium. He classifies the anatomical changes into 
three stages : 

1. The stage of premenstrual congestion, in which the capillaries 
of the mucosa are congested ; a serous or serosanguineous exudate 
infiltrates the stroma of the mucosa, widening the intercellular 
spaces ; later the blood leaves the capillaries and infiltrates the 
stroma, gravitating in the direction of least resistance — i. e., toward 
the uterine cavity, and forming a collection of blood beneath the 
surface epithelium. 

2. The stage of active hemorrhage, in which the blood is forced 
between the epithelial cells into the uterine cavity ; here and there 
the epithelium is lifted from its bed, the continuity of the surface 
is broken, and bits of epithelium are accidentally broken off and 
are carried with the menstrual flow. Blood may also find its way 
into the gland lumina. 

3. The stage of postmenstrual involution, in which the bloodvessels 
become less engorged ; blood is no longer extra vasated into the 
connective tissue spaces ; the blood left in the stroma is slowly 
absorbed ; the surface epithelium lifted from its bed resumes its 
former place, and lost epithelium is rapidly regenerated from 
adjacent epithelial surfaces. 

These three stages are represented in Plate I. The sections here 
illustrated were taken from specimens removed by Dr. J. Clarence 
Webster in the Presbyterian Hospital, Chicago. Five hysterec- 
tomies were performed by Dr. Webster during the various stages 
of menstruation. In the three cases from which these specimens 
were taken the menstrual type was normal ; in the other two there 
was an excessive menstrual flow resulting from endometritis asso- 
ciated with fibroids. Sections from the last two are not presented 
because of the morbid state of the endometrium ; in them the 
surface epithelium was not seen. 

Immediately upon removal the uterus was placed in salt solu- 
tion, taken to the laboratory, and placed in Zenker's solution for 
twenty-four hours. Sections were then made from various parts of 
the endometrium, tubes, and cervix ; they were then carried through 
the usual technic in preparing celloidin sections. 

In all five cases the tubes show no changes, and the cervix is 
somewhat congested. The anatomical changes characterizing men- 
struation are confined to the mucosa of the uterine body. 

While our knowledge of the physiology of menstruation is far 



28 GENERAL DIAGNOSIS. 

from exact, we are in possession of well-established facts relating 
to the anatomy of the menstruating uterus. Moricke, Mandle, 
Gebhard, Herzog, and others have demonstrated beyond dispute, 
as do these specimens here presented, that menstruation is not a 
shedding process, that the loss of epithelium is purely accidental 
and limited. Previous observations were at fault in the technic 
of preparing the sections, and in the selection of material which had 
undergone cadaveric changes and , degenerative changes common to 
infectious and chronic wasting diseases. 



The Menstruating Fallopian Tube. 

It has been the consensus of opinion that the Fallopian tubes do 
not take part in the menstrual act. A few cases have been observed 
where blood collected in the tube during menstruation, and it is 
not proven that in these cases the blood came directly from the 
mucous membrane of the tube and not fom the uterus. (See 
Plate II.) 

UTERINE HEMORRHAGE. 

We read in text-books of menorrhagia and of metrorrhagia — the 
former term applied to an abnormal increase in the menstrual flow, 
and the latter to an intermenstrual flow. I would suggest that 
these terms be dropped from common usage because of the impos- 
sibility of distinguishing between the two in many cases. The one 
so often merges into the other in such a manner as to render impos- 
sible a distinction between a menstrual and an intermenstrual flow. 
Then, too, they are dependent upon the same general causes. For 
the sake of simplicity and exactness, we will include both under 
the general head of uterine hemorrhage. 



DESCRIPTION OF PLATE II. 

Plate II. represents a section of a Fallopian tube removed together with a menstruating 
uterus. A comparison of the section with those shown in Plate I. suggests a close analogy. 
The mucous membrane is engorged with blood, and free blood is found in the mucosa and in 
the lumen of the tube. The epithelium was found intact. 

Since writing the above the author has examined the tubes removed, together with a men- 
struating uterus, finding, as shown in the accompanying plate, changes similar to those in the 
uterus. 



PLATE II 




THE CLINICAL HISTORY. 29 

Systemic Causes of Uterine Hemorrhage. 

Hemorrhage from the uterus may occur as the result of general 
systemic disturbances in the absence of a local lesion. We find 
that ancemia and plethora may cause hemorrhage — anaemia by 
reason of the low specific gravity of the blood and its diminished 
coagulability, and plethora from high vascular pressure. Chlorosis 
is the exception among the anaemias, in that the menstrual flow is 
lessened or absent. We commonly speak of anaemia as the result 
of uterine hemorrhage, when, as a matter of fact, it is not seldom 
the underlying cause. 

All puerpuric conditions may be accompanied by hemorrhage from 
the uterus as well as from other parts of the body. 

The specific infectious diseases may be complicated by hemorrhage 
from the uterus brought about by blood and vascular changes, and 
occasionally by endometritis, in which the cause was a specific infec- 
tion. It is said that emotion will excite a hemorrhage from the uterus. 
I seriously question this statement, for in my own experience I have 
never seen the uterus bleed after a period of mental excitement in 
which there was not found a pathological lesion to account for the 
loss of blood. The mental disturbance serves only as an exciting 
cause of the hemorrhage, but without a pathological lesion there 
would be no hemorrhage. 

Whatever impedes the return flow of blood from the uterus will 
bring about passive congestion in that organ, which in turn may 
result in hemorrhage. In this category may be mentioned dis- 
placements of the uterus, diseases of the heart, lungs, liver, kidney, 
and spleen, abdominal tumors, including ascites, and, lastly, chronic 
constipation. 

Local Causes of Uterine Hemorrhage. 

Subinvolution of the uterus, the result of postabortive infection, 
may be regarded as the most prolific source of pelvic disorders in 
the female. It is the starting-point of many displacements and 
inflammations which eventuate in uterine hemorrhage. The uterus 
is enlarged in all its diameters, and is deeply congested. Such an 
organ rarely maintains its position because of an increase in weight 
and a lack of support from the ligaments and pelvic floor, which 
have been stretched and torn in labor. The usual factors in the 
development of subinvolution are early rising from childbed, 



30 GENERAL DIAGNOSIS. 

traumatisms in labor, and infection following labor, and abortion. 
In this connection it is to be remembered that retained placental 
tissue will result in subinvolution of the uterus, and may remain 
organically attached to the uterus for days, months, and even years, 
keeping up irregular hemorrhages. 

Endometritis is commonly recognized by the symptoms — hemor- 
rhage, pain, and leucorrhoea. One or all of these symptoms may 
be absent, and the diagnosis must finally rest upon the micro- 
scopic examination of scrapings from the endometrium. Indeed, a 
positive diagnosis of endometritis can be made only by the microscope. 
When hemorrhage exists it is usually in the form of an increase in 
the menstrual flow — rarely an intermenstrual flow. Olshausen has 
described a lesion which he calls fungus endometritis, and bases 
his clinical diagnosis upon the presence of hemorrhage in the 
absence of pain and with little or no leucorrhoea. The endometrium 
is greatly thickened and thrown into folds and fungus-like masses, 
which, under the microscope, are seen to consist of a meshwork of 
enlarged and greatly distended glands, with but little interglandular 
connective tissue. Another variety of endometritis, usually result- 
ing in a profuse menstrual flow, is the polypoid. Mucous polyps 
of the uterus are generally of inflammatory origin. Some authors 
believe them to be invariably of inflammatory origin, while all 
admit that they are in large part so. Hemorrhage is not an in- 
variable symptom of polyps of the uterus, and their presence may 
be accidentally discovered by the curette or after the removal of 
the uterus for other reasons. In general, it may be said that 
uterine fibroids of whatever variety can only cause hemorrhage 
from the uterine cavity when the tumor involves the endometrium. 

Fibroids rarely bleed ; the hemorrhage comes from the endo- 
metrium. Furthermore, the hemorrhage is not proportionate to 
the size of the tumor. Submucous fibroids always cause bleeding. 
Intramural fibroids, if in any way influencing the endometrium, 
may cause bleeding, but subperitoneal fibroids cannot. We are, 
therefore, able to determine something of the position of the growth 
by the presence or absence of hemorrhage. 

One of the earliest symptoms of cancer and sarcoma of the uterus 
is hemorrhage. Yet these growths may be far advanced before 
hemorrhage or any other symptom is manifest. It is for this reason 
that malignant diseases of the uterus are so rarely observed in time 
to effect a radical cure. When hemorrhage does make its appear- 



THE CLINICAL HISTORY. 31 

ance it is too often looked upon as an irregularity of the menopause. 
Our statistics in carcinoma of the uterus icould be greatly bettered 
if all hemorrhages occurring at the time of the menopause and after 
this period were viewed with suspicion, and the cause sought for, 
rather than that all irregularities be ascribed to the menopause. 

There is a malignant growth which I will only refer to. It is 
usually called deciduorna, and is a malignant degeneration of 
the placental tissue. Hemorrhage is the earliest symptom, and it 
may be laid down as a rule that when an irregular hemorrhage 
follows late upon childbirth, hydatid mole, or abortion, the possi- 
bility of malignant degeneration of placental tissue must be borne 
in mind. The diagnosis can only be determined by an exploratory 
curettage and microscopic examination of the scrapings. 

When hemorrhage occurs during or immediately after the third 
stage of labor, it is possible that placental tissue is retained in 
the uterus, or that the uterus is relaxed from fatigue and over- 
stretching. 

Improbable as it may seem, death from hemorrhage rarely fol- 
lows rupture of the uterus ; death is more likely to occur from sub- 
sequent infection. 

I will only refer to placenta prsevia, hydatid mole, premature 
detachment of the placenta, and ectopic pregnancy as causes of 
uterine hemorrhage. 

Arteriosclerosis alone has been charged with the responsibility of 
uncontrollable uterine hemorrhage by Herman, Martin, Reinecke, 
and Kiistner. The charge cannot be wholly sustained, because in 
none of their cases is there a record of having excluded other pos- 
sible causes lying beyond the uterus. Reinecke and Martin per- 
formed hysterectomy in thirteen cases for the control of hemorrhage, 
and in all the removed uteri the arteries were found sclerosed ; but 
they did not exclude the possibility of obstruction to the return 
circulation from such causes as diseases of the heart and lungs, 
thrombosis of the venous trunks, and portal congestion from what- 
ever cause. My point is that in the light of twelve cases reported 
by Von Kahlden, Popoff, Herxheimer, and Dietrich, and the one 
I reported, arterio-sclerosis per se may alone be insufficient to cause 
a hemorrhagic infarction of the uterine tissues or hemorrhage into 
the uterine cavity. In the eight cases reported by Von Kahlden 
the postmortem findings showed anatomical hinderances to the 
general circulation. There was pneumonia in two of the cases, 



32 GENERAL DIAGNOSIS. 

pulmonary emphysema and bronchitis in three cases, cancerous 
infiltration of the lungs and liver in one case, pulmonary infarcts 
in another, and in four of the eight cases there were cardiac lesions. 
In the case of Popoff there were granular nephritis and heart 
thrombi, pleural effusion, and infarction of the lung and brain. In 
Herxheimer's case there was an hypertrophied heart and thrombi 
in the left ventricle and right auricle, granular nephritis, and 
atheroma of the aorta. In my own case hemorrhage did not occur 
until there was an additional obstruction to the circulation caused 
by the plugging of the uterine artery. It is, therefore, not conclu- 
sively demonstrated that arterio-sclerosis can in itself be the cause 
of uterine hemorrhage. It would appear that there must be addi- 
tional causes for obstruction, such as were found in the above 
recorded cases. (See Plate III.) 

In the so-called " apoplexia uteri " it is probable that the hemor- 
rhages are not caused by the rupture of the bloodvessels, but rather 
are due to capillary oozing. This would account for the hemor- 
rhagic infiltration being so removed from the sclerosed vessels in 
the cases of Von Kahlden. 

Respecting the etiology of arterio-sclerosis of the uterine vessels 
and hemorrhagic infarction of the uterus, little can be said. Age 
varies within the limits of fifty and eighty-seven years. Pregnancy, 
menstruation, and inflammation of the uterus have some bearing 
upon the etiology. The causes of arterio-sclerosis elsewhere in the 
body would obtain in the uterus — i. e., alcoholism, chronic malaria, 
chronic lead poisoning, syphilis, etc. 

Referring to the frequency of the lesion, it is not unlikely that 
arterio-sclerosis of the uterine arteries and hemorrhagic infarction 
of the uterus are often overlooked in clinical and postmortem 
examinations. It is probable that many cases of so-called " senile 
endometritis " and " hemorrhagic metritis of the menopause " are 
in reality hemorrhagic infarction of the uterus, and have as an 
underlying factor arterio-sclerosis and calcareous degeneration of 
the uterine vessels. The fact that these cases occur in advanced 
years may not be associated with leucorrhoea, and no cause may be 
found for the hemorrhages, either by clinical examination of the 
uterus and adnexa or microscopic examination of scrapings from 
the endometrium, would be strong evidence in favor of the view 
that these cases are not infrequently hemorrhagic infarcts of the 
uterus and that the primary lesion lies in the bloodvessels. 




PLATE III. 



n;,^\^ 









'i 



r - v x y <-/■ 



■ 77 ,?••'/•'/»: ^ ' '.•>;^< i! 7 .--'. . '''• 77i7 : ••< - 

:r\7i7-77^7/V77^-77- 

v;777y/77®7 •■■,■. 7^ 77' 







%#' CA 




Arterio-selerosis and Calcification of the Uterine Arteries. 

M. Musculature. 

E. Endometrium with effused blood. 
C. Calcareous deposits in vessel wall. 
CA. Congested vessels. 



THE CLINICAL HISTORY. 33 

As to the diagnosis, we are usually content to call such cases 
endometritis when there is no demonstrable cause for the hemor- 
rhage. If an exploratory curettage is made with negative find- 
ings, the indefinite diagnosis of metritis will probably be given, 
particularly when the uterus is of dense consistence and uni- 
formly increased in size. It is possible that the increase in the 
connective tissue of the myometrium may interfere with the circu- 
lation, but it is altogether certain that in many cases the primary 
cause lies in the walls of the bloodvessels, and the hyperplasia of 
the uterus is secondary. It is altogether probable that arterio- 
sclerosis of the uterine vessels may exist without symptoms, and, 
as above stated, there probably must be some additional obstruction 
to the return circulation in order to cause hemorrhage, which event 
alone is suggestive of the lesion. The clinical diagnosis is then at 
best uncertain. If hemorrhage occurs in the climacterium or near 
the time of the menopause, and there can be found no local cause 
for the hemorrhage, either in the presence of new-growths of the 
uterus and adnexa, in the position of the uterus, or in the micro- 
scopic examination of the uterine scrapings, then it is fair to 
presume that arterio-sclerosis of the uterine arteries exists. If, in 
addition to this, there is found arterio-sclerosis of the peripheral 
arteries of the body, and there exists a disease of the viscera to 
account for an obstruction in the return circulation from the pelvis, 
then it is further fair to presume that a hemorrhagic infarction of 
the uterus is present, and that the uterine hemorrhages are due to 
a hemorrhage into the tissues and cavity of the uterus. It is not 
probable that the sclerosed vessels will be found in the scrapings, 
because they commonly lie in the outer half of the uterine muscu- 
lature. Caution must be exercised in the liability of mistaking the 
compressed glands for cancer nests. 

Finally, it may be said that the popular imp? % ession that the flow is 
increased in the climacteric leads to disastrous consequences. No 
increase in the menstrual flow at the time of the climacteric should be 
regarded as normal or of no clinical importance. A searching exam- 
ination is imperative. 

The character of the discharged blood varies not only in amount, 
but in color and consistency ; and from these characteristics some- 
thing may be inferred as to the origin of the hemorrhage. The 
menstrual blood is usually thin and of a bright red to a dark brown 
color. Coagulation is hindered by the alkaline reaction of the 

3 



34 GENERAL DIAGNOSIS. 

uterine secretions. Coagulated menstrual blood is always ab- 
normal. 

Coagulation of the blood may occur in endometritis, uterine 
fibroids, carcinoma, polyps, and abortion. When of a dark, 
brownish-red color it is inferred that the passage of the blood has 
been obstructed, giving time for coagulation within the uterine 
cavity. When mucus is intimately mixed with the blood it indi- 
cates an involvement of the cervix from cervical catarrh, polyp, 
carcinoma, or sarcoma. 

Blood of a syrupy consistency is supposed to have remained a 
long time in the uterine cavity. Tissue fibres mixed with the 
blood suggest the presence of degenerated new-growths. 



AMENORRHEA. 

In determining the causes of amenorrhea it is well to bear in 
mind the physiological conditions in which the menses fail to 
appear. A physiological absence of menstruation occurs : 

1. Before puberty. 

2. During irregular intervals at the time of the establishment of 
menstruation. 

3. During pregnancy and lactation. 

4. During the establishment of the climacteric — " dodging 
period." 

5. After the menopause. 

When the menstrual flow is retarded or when the quantity is less 
than normal we speak of the condition as amenorrhoea. The term 
may be further qualified by the words relative and absolute. 

By relative amenorrhoea is meant a menstrual flow that is below 
the normal amount for the given individual. That which is 
abnormal for one may be normal for another, depending upon the 
general condition of the individual. 

By absolute amenorrhoea is meant a total suppression of the 
menses. 

The causes of amenorrhoea are both general and local. 

General Causes of Amenorrhoea. 1. Debilitating diseases, such 
as primary anaemia, Bright's disease, tuberculosis, malaria, and 
nervous diseases. In determining the cause of amenorrhoea it is 
not enough to establish the fact of anaemia, but we must ascertain 



THE CLINICAL HISTORY. 35 

the character of the ansemia by an analysis of the blood, and, if 
possible, demonstrate the underlying cause. 

Among the general causes of secondary anaemias we find two 
groups — those caused by deficient nutrition and those caused by 
increased waste. Digestive and respiratory disorders limit the 
supply of blood and oxygen essential to the proper nourishment of 
the body, and, indirectly, to the performance of the menstrual 
functions. 

Hemorrhage from any part of the body, chronic diarrhoea, con- 
tinued suppuration, albuminuria, and the like results in excessive 
waste that will bring about amenorrhoea. 

2. Changes in environment are often followed by amenorrhoea for 
a variable length of time. Girls coming from foreign countries to 
the United States commonly experience a delay in the appearance 
of the menses for a variable time. 

3. Mental shock and anxiety may cause a suppression of the 
menses. The fear of conception may suppress the menstrual 
periods, and when the fears are allayed the menses may promptly 
return. 

4. " Catching cold " is a term in ordinary usage, implying a con- 
gestion of the pelvic viscera. Part or all of the meuses may be 
suppressed by exposure to cold during and immediately before the 
menstrual period. 

Local Causes of Amenorrhoea. 1. Congenital absence of the 
organs essential to menstruation, namely, the uterus and ovaries. 

2. Hypoplasia and atrophy of the organs essential to menstrua- 
tion. 

3. Retention of the menses from atresia of the cervix and vagina, 
imperforate hymen, and tumor formations obstructing the outflow 
of the menstrual blood. 

4. Removal of the uterus and ovaries, doing away with the men- 
strual flow. 

5. Diseases of the genital organs, disabliug and destroying the 
tissues essential to menstruation — that is to say, metritis, endo- 
metritis, chronic ovaritis, cystic degeneration of the ovaries, and 
new formations in the uterus and ovaries. 

Effects of Ovariotomy on Menstruation. In this relation it is 
interesting to note the effect upon menstruation of the removal of 
the ovaries. After both ovaries are removed menstruation stops 
abruptly in QQ per cent, of cases. In the remaining 33 per cent. 



36 GENERAL DIAGNOSIS. 

menstruation stops gradually throughout a period of one to six 
months. 

The cause of uninterrupted menstruation after double ovariotomy is 
explained by the presence of a supernumerary ovary or by the acci- 
dental leaving of a bit of ovarian tissue adherent to the neighbor- 
ing structures. A small portion of the ovary may have been 
constricted off from the parent ovary by contracting bands of 
adhesions, and may escape notice in the removal of the ovary. The 
law of persistence of habit may explain an occasional case. More 
often a flow persists as the result of a uterine tumor or an inflam- 
matory lesion, and is not, strictly speaking, a menstrual flow. 

Menstrual Molimena. The local and general disturbances which 
occur at the time when the menses should appear, but fail because 
of the above-named causes of amenorrhcea, are included in the term 
menstrual molimena. These disturbances are pain in the region of 
the ovaries, in the back, and radiating to the thighs ; also flushing 
of the face, dizziness, palpitation, and headache. The duration of 
these symptoms varies from a few hours to the entire month. The 
menstrual molimena generally begin about one month after the 
removal of the ovaries, and extend over a period of one or two 
years, sometimes much longer. 

PAIN IN THE PELVIS DURING MENSTRUATION— 
DYSMENORRHEA. 

Pain in the pelvis is often referred to the uterus or ovaries. Of 
all pains in the abdomen the so-called " ovarian pain " is by far the 
most usual. Experience teaches us that pain is referred to the 
ovary of the left side three times as frequently as to the right. 
There is no satisfactory explanation for this. It is a matter of 
every-day clinical experience that the pain is often referred to the 
left ovary when there is no apparent disease in either ovary ; more 
than that, there may be no demonstrable lesion in the pelvis, yet more 
strange is the finding of the lesion in the right ovary and the pain 
referred to the left ovary. The author makes no attempt to 
explain these facts. Certain it is that reflex pains may be located 
in the ovary and the lesion confined to the uterus or opposite 
ovary. We are not to infer from complaints of pain in the ovary 
that this structure is diseased, but such pains may well suggest pos- 
sible lesions in one or more of the pelvic viscera. Such pains are 



THE CLINICAL HISTORY. 37 

particularly frequent and severe at the time of the menstrual period. 
This brings us to the discussion of dysmenorrhea, a term often 
misused and little understood. 

In determining the cause of dysmenorrhea we must first consider 
the condition of the nervous system. A condition causing pain in 
one individual may be unnoticed in another of more stable equi- 
librium. When pain in the pelvis is complained of during and 
between the menstrual periods and a thorough examination reveals 
nothing abnormal in the pelvis, we are in the habit of concluding 
that the fault lies in a functional derangement of the nervous 
system, and we vaguely apply the terms hysteria, neurasthenia, 
and neuroses. A certain degree of pain during the menstrual period 
may be considered within normal limits, and in very nervous 
women such pains may become exaggerated to actual suffering. 

The explanation of the " normal " menstrual pains is probably 
found in the engorgement of the endometrium, which, acting as 
a foreign body, excites the uterus to contract ; and it is these 
uterine contractions which occasion the pain. In many of the 
pathological lesions involving the pelvic viscera the menstrual con- 
gestion is added to the already engorged tissues, and the pain is 
severe. It is exceptional for pathological lesions to exist in the 
uterus and adnexa without dysmenorrhea, but knowing such to be 
possible, and, on the other hand, knowing that pain of equal inten- 
sity may exist in the absence of a pathological lesion, we are at a 
loss to know how much the pain is due to structural changes and 
how much to an excitable nervous system. We may speak of 
idiopathic or primary dysmenorrhoea when it is evident that the pain 
bears no relation to pathological lesions of the genitalia, and of 
secondary dysmenorrhoea when it is evident that the pain is the 
direct result of a morbid condition in the genital tract. 

Secondary dysmenorrhoea may be caused by all lesions of the 
genital tract. These may be classified under : 

1. Maldevelopments and malformations, which cause menstrual 
pain by obstructing the outflow of the menstrual blood. In this 
category may be included absence or atresia of the vulva, vagina, 
and cervix. The menstrual molimena are experienced, but with- 
out a show of blood. With the return of each monthly period the 
pain increases in intensity as the result of accumulated blood within 
the uterus, tubes, and, possibly, the pelvis. The obstruction may 
not be complete, and the retarded blood, having time to coagulate, 



38 GENERAL DIAGNOSIS. 

is then expelled with cramping-like pains — the so-called " obstruc- 
tive dysmenorrhoea." 

2. Malpositions of the uterus and adnexa are less frequently the 
cause of dysmenorrhoea than are the associated lesions. It is 
exceptional for the menstrual blood to be obstructed in its outflow 
by the bending or twisting of the long axis of the uterus. Pain is 
more often the result of complicating lesions in and about the uterus 
and its appendages. 

3. In inflammatory diseases of the uterus and adnexse, which are 
more or less tender and painful in the intermenstrual period, the 
suffering is greatly intensified by the menstrual flux — " conges- 
tive dysmenorrhoea." Plugs of tenacious mucus may fill the 
cervical canal and obstruct the menstrual flow. 

4. New formations in the genital tract may obstruct the menstrual 
blood — "obstructive dysmenorrhoea." Pelvic tumors share in the 
menstrual congestion, and by their enlargement the pressure symp- 
toms are intensified. 

Membranous dysmenorrhea is a term first applied by Morgagni. 
In this condition there is discharge at the menstrual period of a part 
or the whole of a cast of the uterine cavity. The discharge of the 
membrane may occur but once or at each menstrual period. If we 
believed that the endometrium is shed at each menstrual period we 
might conclude that membranous dysmenorrhoea is merely an 
exaggeration of the normal process. The membrane may be shed 
as a complete triangular cast of the uterus, or may be discharged in 
shreds. 

Under the microscope we see a great variation in structure. The 
membrane may resemble an hypertrophied endometrium, a decidua, 
or a fibrinous membrane. 

Accompanying the discharge of the membrane is intense pain. 
The membrane is not to be mistaken for the decidua of extra-uterine 
or intra-uterine pregnancy. 

THE DIAGNOSIS OF THE CAUSES OF STERILITY IN WOMEN. 

Before entering into a discussion of the various causes of sterility 
in women let us clearly understand the clinical significance of the 
term sterility and the conditions essential to conception. 

By sterility we mean an incapacity for childbearing ; this 
definition may be further qualified by the terms " absolute sterility " 



THE CLINICAL HISTOR Y. 39 

and " relative sterility." Sterility is absolute when the individual 
is incapable of bearing a child to the period of viability ; she may 
conceive, but habitually aborts before the period of viability. 
Sterility is relative when childbearing is not in accordance with 
conditions, age, and length of married life. We may speak of 
relative sterility when three years have elapsed since the last child- 
birth, or when conception has not taken place within three years 
from date of marriage — this time limit is, of course, purely arbitrary. 

Again, we may speak of sterility as primary and secondary : 
primary when the conditions which preclude the possibility of child- 
bearing are primary ; secondary when after the birth of one or 
more children there is acquired an incapacity for childbearing. 

The conditions essential to conception are briefly enumerated as 
follows : 

1. Deposit of semen containing living, active spermatozoa in the 
upper segment of the vagina. 

2. Passage of the spermatozoa through the cervix into the cavity 
of the uterus. It is said that spermatozoa will not live longer than 
twelve hours in the acid secretions of the vagina ; while in the 
uterus and tubes they commonly retain their vitality six to eight 
days. Leopold reported a case of a woman in his clinic who had 
not had sexual intercourse for thirty-seven days prior to the opera- 
tion, when, on abdominal section, living, active spermatozoa were 
found in large numbers in the fimbriated end of the tube. This 
case, with many other observations on women and lower animals, 
has led to the statement that fertilization of the ovum commonly 
takes place in the tube. 

3. A healthy ovum must find an uninterrupted passage from the 
ovary, through the tube, and on into the uterine cavity. 

4. The fertilized ovum must find a permanent resting-place on 
the endometrium until the period of viability. 

With the above definitions of sterility and the conditions essen- 
tial to conception set clearly before us, we are now in a position to 
consider the factors which tend to prevent conception. 

In seeking the cause of sterility not only the whole range of dis- 
eases peculiar to women must be considered, but as well the general 
physical and social conditions of the individual. More than this, 
we are not to conclude that the cause of sterility is necessarily 
found in the woman ; full one in six sterile marriages are chargeable 
to the husband. One marriage in ten is non-productive, and, with 



40 GENERAL DIAGNOSIS. 

few exceptions, sooner or later the advice of the physician is sought. 
The subject is, therefore, of prime importance to the physician, and 
no condition more thoroughly taxes the skill of the general practi- 
tioner and specialist. 

In determining the cause of sterility we should first consider the 
general conditions predisposing to sterility, and first of these is age. 
No cause of sterility approaches age in extent and power. The 
most prolific time of life is between the ages of twenty and twenty- 
four. Pregnancy may occur before the menstrual period, as so 
often happens in India, where it is considered a sin to let pass an 
opportunity for conception — a sin eq uivalent to infanticide. Because 
of this belief it is customary to marry before puberty. A case is 
recorded where a woman gave birth to twelve children before her 
menstrual flow appeared. Again, it is possible for pregnancy to 
occur long after the cessation of the menstrual period. Trento 
reported a case of a woman who gave birth to a child at sixty-seven 
years of age. Abraham was one hundred years of age and Sarah 
was ninety when their child was born. Sarah " was old and well 
stricken with years, and with whom it had ceased to be as it is 
with women " — that is, she had ceased to menstruate. So, while 
pregnancy is possible after the menopause, the rule is that the 
capacity for childbearing ceases four to six years before the cessa- 
tion of the catamenia. 

Ancemia, either primary or secondary to some wasting disease, 
such as tuberculosis, diabetes, nephritis, and malaria, is an important 
predisposing factor, and must always be taken into account what- 
ever else may be found. 

Marriage of near relatives is said to be a cause of relative steril- 
ity, but this statement is not confirmed. 

Obesity is undoubtedly a potent cause of sterility. When a 
woman rapidly increases in weight she very often becomes sterile, 
and in such the most promising means of relieving sterility is to 
reduce the weight. 

Alcoholism is an indisputable factor ; furthermore, the death rate 
among children born of inebriate mothers is double that of tem- 
perate parentage. 

The sexual instinct evidently has some influence upon the fertility 
of women. While it is true that many women bear children who 
have never experienced sexual desire, it is the rule that women are 
most likely to conceive who have the greatest sexual vigor. 



THE CLINICAL HISTOB Y. 41 

Sexual excess, on the other hand, conduces to sterility through the 
congestion and inflammation resulting from such excesses. 

Sexual incompatibility is an ill-defined condition that plays a role 
in the causation of sterility, though no explanation is offered. We 
are reminded of the marriage of Josephine and Xapoleon. 

Having considered the above general predisposing causes, we 
now look to the more tangible local factors. 

Dyspareunia is not an uncommon cause of sterility, and in every 
case the underlying cause of painful coition must be determined. 
We look for lesions obstructing the lower genital passage, such as 
acquired and congenital atresia of the vulva and vagina ; over- 
growth of the labia and clitoris, and tumors of the vulva, vagina, 
and uterus, which encroach upon the lower passages. We also look 
for lesions causing pain, such as urethral caruncle, inflammatory 
lesions of any portion of the genital tract ; inflammation of the 
urethra and vagina, and for painful lesions of the rectum, including 
fissure and hemorrhoids. Vaginismus without a recognizable lesion 
is an occasional cause of dyspareunia. It is not essential to concep- 
tion that sexual union be complete. This is demonstrated by the 
fact that pregnancy may occur with an intact hymen and in the 
presence of other evident obstructions to complete sexual union. 

The maldevelopments and malformations of the genital organs are 
occasional causes for absolute sterility. The absence of any of the 
reproductive organs, or the failure of these organs to fully develop, 
are certain causes of sterility. A uterus partially or completely 
divided is not likely to become pregnant, and a septum dividing 
the vagina may offer an obstruction to sexual intercourse. When 
a woman complains of amenorrhcea, or at most of a scanty irregular 
flow which has persisted from a delayed puberty, it is highly pre- 
sumptive that the uterus, together with the tubes and ovaries, has 
failed to develop beyond the infantile type. The ovaries are 
primarily at fault in the majority of cases, and in consequence the 
uterus fails to develop. While there is little encouragement in treat- 
ment of any kind it is manifestly illogical to direct the treatment to 
the uterus rather than to the ovaries — a procedure akin to whipping 
the cart to make the horse go. The complete closure of any portion 
of the genital tract will result in sterility, but these conditions are 
rare, with the exception of closure of the tubes from inflammatory 
adhesions. The influence of stenosis in causing sterility is doubtless 
exaggerated. A congenital narrowing of the cervical canal pre- 



42 GENERAL DIAGNOSIS, 

vents the passage of spermatozoa, but in such cases there is usually 
an under-development of the uterus, and possibly the ovaries as 
well to account for the sterility. 

The vagina may be too short or too narrow to retain the semen, 
and the cervix may be too long to allow the entrance of the sper- 
matozoa from the vault of the vagina A short cervix per se is not 
a cause for sterility ; not infrequently the explanation lies in an 
under-development of the uterus. 

A frequent cause of secondary sterility is superinvolution of the 
uterus brought about by superlactation, infection, and malnutrition. 

Malpositions as direct causes of sterility have been greatly over- 
rated. Pregnancy is possible in all malpositions of the uterus with 
the exception of complete inversion. We are forced to conclude 
that the underlying cause is more often in accompanying inflam- 
matory lesions and in dyspareunia. Chronic endometritis and 
ovaritis are so commonly associated with displacements, and are 
such potent causes of sterility, it is fair to assume that they are 
most often the underlying cause. 

The displaced cervix is a more likely cause than is the displaced 
body of the uterus. The difficulty with which the semen enters 
the cervix when displaced forward, or to the side in backward or 
lateral displacement of the uterine body, will account for sterility, 
whereas it is difficult to conceive of the cervical canal being 
obstructed by the flexion of the body upon the cervix. The thick 
resisting wall of the uterus will not permit of so sharp bending as 
to obstruct the passage of spermatozoa. Reasoning a priori, an 
extreme retroversion with the cervix pointing upward and forward 
would more likely cause sterility than would an uncomplicated 
retroflexion with the cervix pointing downward and backward. 
From like reasoning descent of the uterus, especially when asso- 
ciated with elongation of the cervix, as is usually the case, would 
be still more likely to result in sterility because of the difficulty of 
the semen gaining entrance to the cervical canal. 

Traumatisms of the cervix and vagina not infrequently predis- 
pose to sterility. A lacerated perineum allows of the free escape 
of semen from the vagina, and a lacerated cervix followed by 
erosion and eversion of the cervical mucous membrane may offer 
an obstruction to the semen. Rectovaginal and vesicovaginal 
fistulse cause sterility by the effect of the urine and feces upon the 
semen, by the accompanying vaginitis and the resulting dyspa- 



THE CLINICAL HISTOR Y. 43 

reunia. Cicatricial con traction of the vagina following an injury 
may interfere with sexual union. 

Pelvic inflammation is by far the most prolific source of sterility, 
and first among the various lesions is endometritis. The hyper- 
plastic form of endometritis will most certainly cause sterility, and 
particularly when associated with profuse hemorrhages and leu- 
corrhoea. The diseased endometrium is an unfavorable resting 
place for the ovum, and the discharges play havoc with the sper- 
matozoa. In the cervix the increased mucous secretions of endo- 
cervicitis plug the cervical canal so effectually as to prevent the 
entrance of the semen. Vulvovaginitis may prevent conception 
through perverted acid secretions and dyspareunia. Infections of 
the tubes destroy the cilia and often as well the epithelium, thereby 
hindering the progress of the ovum. Closure of the fimbriated end 
of both tubes, resulting in a distention of the tube with serum, blood, 
or pus, will almost certainly cause permanent sterility. Yet it is 
of interest to know that pregnancy has followed upon the disap- 
pearance of double pyosalpinx. 

A chronic inflammation or passive congestion of the ovary results 
in a hyperplasia of the connective tissue surrounding the follicles, 
and in a thickening of the tunica albuginea and in possible 
adhesions surrounding the ovary. All this renders difficult or 
impossible the escape of ova into the tube. 

In pelvic cellulitis and pelvic peritonitis constricting bands of 
adhesions may obstruct the lumen of the tube, and so displace the 
uterus, ovaries, and tubes as to cause sterility. In all these forms 
of infection dyspareunia is a large factor in the causation of sterility. 

New formations as causes of sterility are yet to be considered. In 
general, they operate through mechanical obstruction. By their 
presence an inflammatory reaction may develop as the prime cause 
of the sterility. Degeneration of the tumor leading to an irritating 
discharge acts in a deleterious manner upon the spermatozoa. The 
size of the growth is not of so much consequence as the position ; a 
small fibroid in the cervical canal may cause complete obstruction, 
while pregnancy may go on to full term in subperitoneal fibroids 
of enormous size. Malignant growths rarely cause sterility, because 
the childbearing period is usually at an end before the advent of 
either carcinoma or sarcoma. Sterility associated with amenorrhoea 
in the presence of an ovarian cyst suggests the possible presence of 
a similar involvement of the other ovary. 



44 GENERAL DIAGNOSIS. 

THE MENOPAUSE. 

The average time of appearance of the change of life is from 
forty to fifty-five years of age. The earliest recorded natural meno- 
pause began at twenty-four years of age, the latest at seventy. The 
factors influencing the time of appearance of the menopause are : 

1. Climate. The colder the climate the later the menopause. 

2. Social State. Sir Andrew Clark states that the menopause 
occurs earlier in the more civilized and cultured classes. 

3. Race. The Jews reach the menopause at an earlier time than 
the average woman in the same climate. 

4. Heredity. It has been frequently observed that heredity has 
a determining influence upon the establishment of the menopause ; 
this tendency toward an early or late menopause may persist 
through several generations. 

5. General and Local Diseases : 

(a) Those favoring an early climacteric are atrophy of the uterus 
and ovaries, superin volution of the uterus, chronic metritis and 
ovaritis, and the general wasting diseases. 

(b) Those favoring a late climacteric are malignant growths and 
fibroids of the uterus, endometritis, subinvolution of the uterus, and 
chronic metritis. 

The climacteric has an average duration of three to four years, 
during which time the menstrual periods commonly recur at longer 
and longer intervals as the flow becomes more and more scant ; this 
is known as the " dodging period. " 

In about one woman in seven the menses stop suddenly and 
permanently. 

The clinical manifestations of the menopause are most varied. 
They are seldom wholly absent, nor are they constantly present. 
As a rule, they recur at irregular intervals. 

The general phenomena associated with the menopause are nervous 
disturbances, such as irritable temperament, despondency, forgetful- 
ness, fainting, vertigo, flashes of heat and cold, perversion of taste, 
loss of sexual desire, and occasionally a homicidal or suicidal 
tendency. 

The local phenomena are atrophy of the genital organs and of the 
breasts, and in many cases an increase in the body weight. There 
are no facts to substantiate the statement that the development of 
skin diseases is influenced by the menopause. 



THE CLINICAL HISTOR Y. 45 



LEUCORRHCEA. 

Any discharge from the vulva that is not blood is popularly 
called " whites " or leucorrhoea. When the secretion departs from 
the normal in color, consistency, odor, irritability, and amount, 
there must exist either a functional or an organic lesion of the 
genital organs. It is of the greatest importance to determine the 
character and source of the secretion. 

The normal secretions of the genital organs are : 1. From the 
vulva the ordinary secretions of sebaceous and sweat glands. The 
Bartholinean glands lying in the labia majora secrete mucus, par- 
ticularly during sexual excitement. The reaction is alkaline, and 
the amount is scarcely noticeable. 

2. The vagina does not ordinarily contain glands, but occasion- 
ally a few are found in the vault of the vagina. The vagina has 
essentially a skin surface, having no secretion under normal condi- 
tions. The so-called vaginal secretion is the accumulated outpour 
of the uterine body and cervix mixed with epithelium and bacteria. 
The secretion is acid in reaction as the result of the action of certain 
bacteria changing the alkaline secretion of the uterus to an acid 
reaction. 

3. The secretion of the cervix is mucus. It is tenacious and 
alkaline in reaction. 

4. The secretion of the endometrium is serous and sufficient in 
amount to moisten the surface ; it is alkaline, clear, and transparent. 

For clinical purposes we will consider leucorrhoea as it occurs in 
the various periods of life. 

Leucorrhoea in Infants. In children a leucorrhoeal discharge 
seldom arises from a point above the hymen. As a rule, it is the 
expression of a vulvitis, which, in turn, is caused by soiled diapers, 
intestinal worms, highly acid urine, gonorrhoea, masturbation, and 
the strumous diathesis. The vulva appears swollen and reddened, 
is tender to pressure, and is covered by a slimy secretion. 

Leucorrhoea in Virgins. In young girls it is not unusual for a 
transient leucorrhoea to appear from time to time. No pathological 
basis for the leucorrhoea can be discovered further than a possible 
pelvic congestion. Persistent leucorrhoea may be due to the same 
causes found in childhood. As in infants, the lesion is commonly 
a vulvitis, and is rarely found above the hymen. The secretion is 
seldom sufficient to more than moisten the vulva, and rarely calls 



46 GENERAL DIAGNOSIS. 

for a local examination. Anaemia is always to be considered in 
determining the contributing factors. 

Leucorrhcea in the Period of Sexual Maturity. The secretion 
may come from any portion of the genital tract — from the vulva, 
vagina, cervix, body, and tubes. In the vast majority of cases the 
cause may be ascribed to gonorrhoea and to labor and abortion. The 
most profuse leucorrhcea is occasioned by gonorrhoeal infection. In 
addition to these causes may be mentioned instrumental and digital 
inspection, displacements of the uterus, passive congestion due to 
an interference with the return supply of blood from diseases of 
the heart, lungs, liver, kidney, and spleen, and also to abdominal 
tumors, to acute infectious diseases, and to all benign and malignant 
new formations of the vulva, vagina, and uterus. 

Not only the cause but the source of the secretion must be deter- 
mined. Shultze devised the following method of demonstrating 
the source of the secretion : Following a vaginal douche of sterile 
water a large tampon of sterile absorbent cotton is placed against 
the cervix and left there for several hours. If the secretion comes 
from the uterus, it will collect upon the top of the tampon and can 
be examined for bacteria and other elements. If the secretion is 
mucus and in small amount, it must come from the cervix ; if 
watery and abundant, it comes from the body of the uterus, rarely 
from the tubes — " hydrosalpinx profluens." 

It is of importance to distinguish between a hypersecretion of the 
endometrium and a discharge due to some pathological lesion. This 
is often difficult, and may be impossible. Women will often com- 
plain of a leucorrhcea immediately preceding and following the men- 
strual flow. As a result of the congestion which precedes the 
monthly flow one or more days and continues a variable time after 
the cessation of the bloody flow, there is a hypersecretion of the 
glands sufficient to give rise to a seromucous discharge. 

Leucorrhcea in Old Women. In the aged leucorrhcea has a more 
serious significance. The source is the vulva, vagina, and uterus. 
Senile vaginitis, vulvitis, and endometritis are the most common 
causes. 

In the case of all unusual discharges from the genital tract of 
women advanced in years, whether the discharge be watery, bloody, 
purulent, or ichorous, there is always a suspicion of malignancy, 
and this thought is uppermost in the search for the underlying 
cause. Gonorrhoea infecting the aged rarely involves the uterus and 



THE CLINICAL HISTORY. 47 

tubes. The infection is generally limited to the vagina and urethra. 
The irritation of a filthy and ill-fitting pessary will occasion a 
vaginal discharge. 

Malignant growths give at first a watery discharge, which later 
becomes turbid, bloody, and foul-smelling. Cancer of the body of 
the uterus is more common after the menopause than is cancer of 
the cervix ; therefore, in seeking the cause of a suspicious discharge 
occurring after the menopause it may be necessary to explore the 
uterine cavity with a curette. The discharge of a senile endome- 
tritis may simulate that of a malignant growth, and nothing short 
of an exploratory curettage with a microscopic examination of the 
scrapings will establish the diagnosis. 



CHAPTER II. 

PHYSICAL EXAMINATION. 

Preliminary Measures. Having taken the history as outlined 
in the previous chapter, the next step is to determine by a general 
physical examination the possible bearing which some remote affec- 
tion may have upon the pelvic organs. 

Confining ourselves more particularly to the abdomen and pelvis, 
we will proceed to outline the method to be employed in a sytematic 
and thorough physical examination, and will describe the methods 
in the order in which practical experience has sanctioned their 
usage. 

No invariable order can be adopted ; circumstances will alter the 
general routine ; but it is well to follow a definite method of pro- 
cedure as closely as possible. The habit of making a systematic 
routine examination will not infrequently eliminate many errors 
in diagnosis. The examiner will not likely be content with the 
finding of any single explanation for the patient's complaint, but 
will seek further for other possible lesions. The writer recalls a 
case in which hemorrhage was the symptom complained of. On 
physical examination an interstitial fibroid was discovered. This 
was believed to explain the hemorrhage, and a hysterectomy was 
performed. In the cavity of the uterus was a cauliflower car- 
cinoma, which had not been suspected. The examination had not 
been complete ; when a single cause for the hemorrhage was dis- 
covered no further search was made. Had a more conservative 
operation been performed and the uterus not removed, the more 
serious of the lesions would have been overlooked. 

In making a physical examination care should be taken for fear 
of injury to the structures examined ; and the examiner will always 
endeavor to avoid inflicting pain. The more skilled the examiner 
the more careful and gentle he will be. A vaginal examination 
may cause great discomfort, and serious damage may be done to 
an inflamed mucous membrane and malignant growths. As the 
result of a bimanual examination roughly made, not only much 



PHYSICAL EXAMINATION. 



49 



suffering may be caused, but cysts may be ruptured, abscesses may 
break into the peritoneal cavity, the gestation sac of an ectopic 
pregnancy may burst, adhesions may be torn, and in the use of the 
sound, curette, and speculum, serious and even fatal injuries may 
be sustained. While an exact diagnosis is desired in the first 
examination, it is seldom absolutely necessary and is frequently 
impossible. Certain procedures, such as catheterizing the ureters, 
must often be postponed for a subsequent examination 



Fig. 1. 




Examining table. (Schmidt.) 

It is seldom necessarv to make an examination during the men- 
strual period. It is not only objectionable to the patient, but at such 
times the pelvic viscera are congested and there is an added risk 
of injury. During the menstrual period the cervix is softened and 
somewhat patulous, and for this reason Simpson has advised the 
exploration of the uterine cavity during menstruation for the detec- 
tion of foreign growths. The added risk of infection and injury at 
such times would seem to contraindicate such a practice. 

We therefore elect the intermenstrual period for local examina- 
tions and treatments, for the reasons that the conditions then found 



50 GENERAL DIAGNOSIS. 

are more nearly normal and there is less risk of injury. Further- 
more, it is best to make the examination at a time when the patient 
is in a condition the nearest possible to the normal. To this end 
the examination should not be made immediately after a full meal, 
or when for any reason the patient is exhausted and nervous. 

Whenever possible the patient should be examined on a table 
with good light. Whatever table is used it should be of convenient 
width and length to permit the patient to assume any desired posi- 
tion. It should be so placed as to be approached by the examiner 
from all sides, and should be of convenient height to allow the 
examiner to proceed without assuming an unnatural and strained 
attitude. Fig. 1 shows a correct table for the making of examina- 
tions and operations. This table was designed by Dr. L. E. 
Schmidt, of Chicago, and has the special advantage of directing 
the buttocks well over the edge of the table, thereby favoring 
instrumental examinations of the bladder, vagina, and rectum. 

We are often obliged to examine a patient on a bed or a couch. 
The author does not favor the examining chair because of its 
formidable appearance, its cumbersome weight, and the incon- 
venience with which the position of the patient is changed. 



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CHAPTER III. 

EXTERNAL ABDOMINAL EXAMINATION. INSPECTION OF 
THE ABDOMEN. 

It is well to expose the abdomen by removing the corset and all 
constriction about the waist. A sheet should cover the upper portion 
of the trunk to the waist line ; another sheet should cover the lower 
extremities and hips, as seen in the accompanying illustrations. 

The chief value of inspection is to determine abnormalities in the 
contour of the abdomen. We are to observe the size of the 
abdomen, its form, the site of a convexity or depression, the laxity 
or tension of the abdominal wall, the retraction or distention of the 
umbilicus, the presence of linea albicantes, pigmentations, distended 
veins, a hernia, skin diseases, peristaltic movements of the intestine, 
pulsations of the aorta as seen through the thin abdominal wall, 
and fetal and respiratory movements. Variations in the contour of 
the abdomen produced by tympany, ascitic fluid, tumors, and thick 
parietes are readily recognized by a competent observer. 

In a thick, fatty abdominal wall the abdomen is flattened and the 
flanks protrude and sag downward when the patient lies on her 
back. Great transverse folds are formed. (See Plate IV.) 

Free ascites with the patient in the dorsal position causes a bulg- 
ing in the flanks and a flattening of the anterior abdominal wall. 
With change in position of the patient the contour of the abdomen 
is altered. (See Plate V.) 

In ovarian cysts the abdomen is irregularly ovoid. In the very 
large cysts, or where the pedicle is long and the cyst is freely mov- 
able, the abdomen may be evenly distended. When the abdominal 
wall is thin and the cyst large and multilocular, it is sometimes 
possible to see the irregular elevations through the abdominal wall. 
(See Plate VI.) 

Large uterine fibroids may evenly distend the abdomen, but more 
frequently cause an irregular protuberance. (See Plates VII, and 
VIII.) In interstitial fibroids the abdominal enlargement is 
inclined to be more median than in ovarian cysts. 

In excessive distention of the abdomen the skin is white and 
shiny, and often streaked with irregular red lines. 



CHAPTER IV. 

PALPATION OF THE ABDOMEN. 

The abdomen is best palpated with the patient in the dorsal 
position. The head and chest if elevated will diminish the field of 
exploration. When it is desired to note the effect of change in 
position upon the abdominal contents, the erect, the knee-elbow, or 
the lateral position may be assumed. 

Preliminary to all abdominal and pelvic examinations the bladder 
and rectum must be empty and all constricting bands of clothing 
removed. The examiner's hands should be warm and the finger- 
nails cut short. Both hands should be used. They should be laid 
gently upon the abdomen, the pressure steady and firm, avoiding 
all sudden and unexpected movements. The patient should be 
instructed to breathe quietly, with the mouth open. Her attention 
may be drawn from the examination by asking questions concern- 
ing some other portion of her body. In this manner, with thin 
and relaxed abdominal walls, it may be possible to palpate the 
projecting vertebrae, the posterior wall of the pelvis, the promontory 
of the sacrum, and the pulsating aorta. 

Thick and tense abdominal walls may prevent satisfactory pal- 
pation of the abdomen, necessitating an anaesthetic. Very often by 
care and patience the tendency to contract the abdominal walls may 
be overcome without resorting to anaesthesia. Remember, that it 
is possible to do harm by. rupturing collections of blood, cysts, and 
abscesses, and by exciting a limited or latent inflammation. 

For convenience of description the abdomen may be divided into 
quadrants (Fig. 2). 

These are named respectively the right upper, the left upper, the 
right lower, and the left lower quadrant. 

Before determining the nature of a swelling, it is necessary to 
identify it either as growing from the pelvis or from the abdomen, 
and to demonstrate its relation to the viscera and the abdominal 
wall. 

It is well to follow a routine system, beginning below and pro- 
ceeding upward. If the preliminary step of emptying the bladder 



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53 



and bowels is taken there should be no confusion with a fecal tumor 
and distended bladder. All tumors of the abdominal wall move 
with the wall, and may be lifted up with it. The connection of a 
tumor with the skin is recognized by inability to lift the skin apart 
from the tumor. 

Fig. 2. 



*0r 



Upper Right 
Quadrant 



Lower Right 
Quadrant 




Upper Leff 
Quadrant 



_ 



Lower Left 
Quadrant 





Diagram of the areas into which the abdomen may be divided. 



All intraperitoneal organs and viscera move with respiration. 
The nearer the diaphragm the greater the excursion. If the organ 
or tumor is adherent or is incarcerated the excursions will be 
limited. These isochronous respiratory movements are readily 
recognized by the hand, and under favorable conditions may be 
recognized by inspection. An organ or tumor lying underneath 
the peritoneum, if protruding into the peritoneal cavity, may be 
affected by respiratory movements. Such, for example, is the case 



54 GENERAL DIAGNOSIS. 

with a movable kidney and a pedunculated subserous fibroid. All 
tumors arising in the pelvis tend to grow upward. 

The contour of the swelling and its consistency are determined 
by palpation. It is important to recognize periodical alterations 
in consistency in connection with the differential diagnosis between 
pelvic and abdominal swellings and a pregnant uterus. No swell- 
ing other than a pregnant uterus contracts intermittently. The 
softening of a tumor speaks for a degenerative process. When the 
swelling is deep-seated or the abdominal wall thick and tense, it 
may be impossible to determine the consistency and contour of the 
swelling. Fluctuation is best detected by percussion associated 
with palpation, and when elicited speaks for the presence of fluid. 
According to the readiness of response to impulse, we may judge to 
some extent of the consistency of the fluid. The examiner is often 
at a loss to decide whether or not fluid is present. Tense cysts 
may not fluctuate, and, on the other hand, soft tumors may appear 
to fluctuate. 

The connection of the swelling with other tumors and viscera 
may be determined by palpation. The exact location of the tumor 
is noted, and by palpation is often traced to a particular organ. 
By changing the position of the patient we may gain additional 
information regarding the attachment of the swelling. Spencer 
Wells has pointed out that non-adherent pedunculated tumors of 
the pelvis gravitate into the abdominal cavity when the knee-chest 
position is assumed. 



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CHAPTER V. 

PERCUSSION OF THE ABDOMEN. 

The abdomen is best percussed with the patient in the dorsal 
position. When it is desired to demonstrate by percussion the 
change in position of a tumor or fluid the patient may assume 
any required position. 

Since the normal percussion tone of the abdomen differs according 
to the contends of the stomach and bowels, the results obtained by 
percussion are not altogether reliable. The normal range of motion 
in the abdominal and pelvic viscera also adds to the uncertainty of 
the conclusions arrived at by percussion. Furthermore, we cannot 
compare the percussion note on corresponding sides, as is done in 
percussing the chest. 

In proceeding it is well to go over the entire abdomen in a sys- 
tematic manner. If firm pressure is made by the fingers the 
intestines, unless adherent, will be pushed aside, and the underlying 
organ or tumor can be directly percussed. Percussion is of the 
greatest value in demonstrating the presence or absence of intestine 
lying in front of the organ or tumor. All other conditions are 
better elicited by palpation. 

By reference to the accompanying diagrams it will be seen that 
in ascites (Plates IV. to IX.) the dull percussion note of the fluid 
is found in the most dependent portion of the abdomen, and the 
tympanitic note of the intestine is found above the fluid. Where 
the mesentery is short or the bowel fixed by adhesions, the above 
findings are not elicited. If gas does not distend the intestine, or 
if fecal matter fills the intestine, the tympanitic note is not elicited 
in contrast to the dull note of the fluid. 

Where the ascitic fluid greatly distends the abdomen there may 
be no change in the area of dulness. Where there is a small 
amount of ascitic fluid the intestine may float to the side of the 
abdomen and give a tympanitic note together with fluctuation. 

When an ovarian cyst (Plate VI.) distends the abdomen the per- 
cussion note is dull in front and the tympanitic note of the intestine 
is found low in the sides. 



CHAPTEK VI. 

AUSCULTATION AND MENSURATION OF THE ABDOMEN. 

Auscultation is of little value except in the diagnosis of 
pregnancy. Other than the sounds referable to the foetus, the 
placenta, and the pregnant uterus, there may be heard over the 
abdomen the maternal heart tones, pulsation of the aorta, murmur 
of abdominal aneurisms, gurgling of gas in the bowel and stomach, 
and the friction sounds caused by the rubbing together of rough 
surfaces. 

The patient should be in the dorsal position, with the legs suffi- 
ciently flexed to relax the abdominal walls, yet not to the extent 
of interfering with the examination. The ear or stethoscope may 
be employed, preferably the latter. 

The uterine bruit is not to be mistaken for the bruit that is heard 
in about 50 per cent, of uterine tumors and occasionally in ovarian 
cysts. A similar bruit has been heard over the tumors of the liver, 
spleen, and the retroperitoneal spaces. No such sound has been 
heard over tumors of the kidney. 

Mensuration is of some importance in the diagnosis of abdom- 
inal swellings. It finds its greatest service in obstetric practice. 
It is a fairly precise means of determining the rate of growth of an 
abdominal swelling. 

Exact measurements are difficult, because of the variable degree 
of distention of the intestine and the shifting of the abdominal 
tumor. There must be a convexity of the abdomen ; otherwise, 
comparative measurements would be of no value. 

An ordinary tape-measure will answer the purpose. The meas- 
urements to be taken are : the greatest circumference, the circum- 
ference at the level of the umbilicus, the distance from the ensiform 
cartilage to the pubis, from the umbilicus to the anterior-superior 
spine of the ilium on either side, and the distance from the linea alba 
to the spine of the vertebrae. It is important for the purpose of 
comparison that the same position be assumed in making subse- 
quent measurements. 



CHAPTER VII. 

EXAMINATION OF THE EXTERNAL GENITALS. 

The routine practice of inspecting the external genitals is 
unnecessary, and should be discountenanced. When required the 
Sims position or the ordinary lithotomy position is assumed. The 
sheet is drawn about the lower extremities and tucked about the 
vulva in such a manner as to make the least possible exposure. 
The labia are held apart by the thumb and index finger for the 
inspection of the vestibule, urethral opening, hymen, and perineum. 

When gonorrhoea is suspected the urethra and Bartholinean 
glands should be inspected. When these structures are infected, 
and particularly if pus can be expressed from the urethra, the diag- 
nosis of gonorrhoeal infection amounts to a moral certainty. 

Recent injuries should be inspected, but long-standing injuries 
to the pelvic floor can be detected and a fair estimate of their extent 
gained from the sense of touch alone. 

Malformations, pigmentations, varix, oedema, and all the new 
formations should be examined. 

DIGITAL EXAMINATION OF THE INTERNAL GENITALS. 

The hidden position of the internal genitals makes it necessary 
to examine them through one or more of the natural openings — 
rectum, bladder, and vagina. Until the end of the eighteenth 
century the vaginal route was the only one used. Little progress 
was made in the diagnosis of diseases of the internal genital organs 
until the introduction of combined methods of examination were 
introduced by M. Puzos, in the eighteenth century, and revived 
and elaborated by Sir James Y. Simpson. By the combined exam- 
ination we have the only means of determining the size, position, 
consistency, mobility, sensitiveness, and connections of the pelvic 
organs. 

Digital Examination of the Vagina. This is made with the 
patient in the Sims or lithotomy position, rarely in the erect or 



58 



GENERAL DIAGNOSIS. 



knee-chest position. Thin rubber gloves or finger-cots are advised, 
not only to prevent infection of the patient, but as a protection to 
the examiner. With some practice the gloves will not embarrass 
the sense of touch to any considerable extent. When the bare 
hand is used it should be scrubbed with soap and water and disin- 
fected with lysol. The most elegant lubricant for the examining 
finger is scented green soap. Vaseline is not desirable, because of 
the odor from the secretions, which clings to the fingers in spite of 
vigorous scrubbing. In an ordinary digital examination of the 
vagina it is unnecessary to expose the vulva ; the examination may 
be made in a perfectly satisfactory manner under cover of a sheet. 

Fig. 3. 




FULL SIZE 



It should be the invariable practice of physicians to wear a thin 
rubber glove or finger-cot (Fig. 3) in making vaginal and rectal 
examinations. This is done not only as a matter of cleanliness 
in preventing septic infection of the genital organs, but as well to 
prevent infection of the examining finger. A well-known authority 
on skin and veneral diseases told me that an average of one physi- 
cian a week came to his office with a syphilitic infection acquired 
in making examinations. This appalling statement should make 
us very cautious. 

. The attitude of the examiner should be carefully considered. 
Fig. 4 shows the correct position. The examiner stands at the end 
of the table ; one foot rests upon a low stool ; the elbow of the 
examining arm rests upon the knee, thereby permitting free motion 
in the forearm and hand. 



EXAMINATION OF THE INTERNAL GENITALS. 



59 



The choice of hand will depend in part upon the comparative 
utility of the two hands, but more upon the habit acquired. As a 
general thing, the right side of the pelvis is best palpated with the 



Fig. 4. 




Combined vaginal examination. 



left hand, and the left side with the right hand. In the early 
experience of the examiner it is best to cultivate the sense of touch 
in a single hand, and in later years, as there are opportunities for 
more experience, either hand may be used, with equal expertness. 



60 



GENERAL DIAGNOSIS. 



Shall One or Two Fingers be Used in Digital Examinations of the 
Vagina ? Where two fingers can be introduced without discomfort 



Fig. 5. 




Lithotomy position. 



Fig. 6. 




Knee-chest position. 



to the patient, the two will be found more effective than one. In 
order that the fingers may be introduced with the least possible 
annoyance to the patient, the labia are separated by the thumb and 



EXAMINATION OF THE INTERNAL GENITALS. 61 

Fig. 7. 




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Erect position. 



62 GENERAL DIAGNOSIS. 

index finger. The middle finger of the opposite hand is inserted 
into the vulvar opening, with the palmar surface resting upon the 
perineum. Firm pressure is made by the finger upon the perineum. 
The vulvar outlet is thereby deepened, and into it the index finger 
can be readily inserted. The two fingers are now passed into the 
vagina, making firm pressure upon the perineum and avoiding 
pressure upon the clitoris and urethra. When the fingers are fully 
inserted the palm of the hand is turned upward. When the vulvar 
outlet is small, the mucosa sensitive or the hymen intact, a single 
finger should be employed. Where pain is caused by inserting the 
finger, it is well to ask the patient to bear down while the examina- 
tion is being made. 

The following conditions are determined by a simple vaginal 
examination : the size, form, and position of the vulva, vagina, 
and vaginal portion of the cervix ; the condition of the hymen, 
whether present or absent, perforate or imperforate ; the integrity 
of the pelvic floor ; the presence of new-growths in the vulva,- 
vagina, and vaginal portion of the cervix ; sensitiveness and fulness 
in the vault of the vagina and the capacity of the pelvic outlet. 

The knee-chest position is especially used when it is desired to 
do away with intra-abdominal pressure for the purpose of permit- 
ting the uterus and freely movable pelvic tumors to rise out of the 
small pelvis. 

The erect position is practised chiefly in determining the degree 
of prolapsus of the uterus. 

After concluding the examination the finger is withdrawn and 
the secretion on the finger inspected. 

The Combined Vaginal Examination (Bimanual). The advan- 
tages of a combined examination over a simple vaginal or 
rectal examination are evident. The combined method may be 
regarded as the most valuable of all physical explorations of the 
pelvis. Various combinations may be utilized, they being desig- 
nated as abdomino-vaginal, abdomino-rectal, abdomino- vesical, 
abdomino-vesico-vaginal, abdomino-vesico, and rectovaginal. 

As preliminary steps to the examination the bladder and rectum 
are emptied, all clothing made loose about the waist, and the 
patient placed in the lithotomy position. 

Abdomino-vaginal Examination. In order that this method of 
examination be properly performed, the vagina must be patent and 
its walls relaxed. Furthermore, it is essential that the abdominal 



EXAMINATION OF THE INTERNAL GENITALS. 



63 



walls be sufficiently thin and relaxed to permit of depression. 
Where there is much fat in the abdominal wall, a pendulous abdo- 
men, or tenderness and pain on pressure, little or nothing can be 
accomplished by this method without the aid of an anaesthetic. In 
extreme elongation of the vagina, and when there is an excessive 
deposit of fat in the external genitals and thighs, it may be impos- 
sible to palpate high in the vault of the vagina. 

The bimanual examination is best performed in the lithotomy or 
dorsal position, with the thighs slightly flexed. Little can be 
gained from such an examination with the patient in the erect or 
knee-chest position. The side positions, while awkward and ill- 
adapted for general use, are of special service in testing the mobility 
of the pelvic viscera and tumors. 



Fig. 




Sims' position. 

All that has been said in describing the digital examination of 
the vagina concerning the choice of hands, the use of one or two 
fingers, and the manner of introduction of the fingers, will apply to 
the combined method of examination. The function of the hand 
upon the abdomen is to steady the pelvic organs while palpated by 
the fingers in the vagina. A complete outlining of the pelvic 
viscera by the external hand is not possible, consequently light 
pressure is all that is required, and has the advantage of not excit- 
ing the abdominal muscles to contract. The tips of the fingers are 
directed toward the ensiform cartilage and gradually made to com- 
press the abdominal wall at a variable point above the symphysis 
pubis. With a thin, flaccid, abdominal wall, and in the absence of 
large swellings, the external and internal fingers may be approxi- 



64 



GENERAL DIAGNOSIS. 



mated in front of the uterus with only the vaginal wall, the bladder, 
and the abdominal wall intervening. Under most favorable con- 
ditions the fingers may be similarly approximated behind the 
uterus. Lifting the uterus forward and upward by the finger in 
the vagina the uterus may be palpated over the entire surface of 
the body, and at the same time the vaginal and supravaginal sur- 
face of the cervix may be outlined by the finger in the vagina. In 
anteversion of the uterus the anterior surface of the uterine body is 

Fig. 9. 




Abdominovaginal examination. 

best palpated by the finger in the vagina, and the posterior surface 
by the external fingers. In retro versio-flexion the posterior sur- 
face of the uterus is best palpated by the finger in the vagina and 
the anterior surface by the external fingers. When the uterine 
body is enlarged it may be readily outlined in the conjoined exam- 
ination without elevating the uterus by pressure from below. 

Under favorable conditions it is possible to determine the position 
of the uterus ; its size, form, sensitiveness, consistency, and mobility. 



PLATE X 



\ 




Palpation of the Pedicle of an Ovarian Cyst. 

Two fingers are inserted into the rectum and the opposite hand over the abdomen. An assistant 
makes traction upon the cervix with a vulsella forceps while a third assistant grasps the cyst 
with both hands and draws it upward. In this manner the pedicle is put upon the stretch and 
can be engaged between the fingers in the rectum and those on the abdomen. 



EXAMINATION OF THE INTERNAL GENITALS. 65 

No manipulating should be done until the position of the uterus 
is determined, and this is largely accomplished by vaginal touch. 
Pressure by the examining fingers may correct or exaggerate a 
malposition of the uterus. A preliminary vaginal examination will 
serve to eliminate such errors. For details of the method of exam- 
ination in displacements of the uterus, see Chapter XXI. 

The Fallopian tubes, under ordinary conditions of health, cannot 
be palpated in a combined examination. With conditions most 
favorable, in which the abdominal walls are thin and relaxed, the 
vaginal walls distensible, and the tubes in their normal position, it 
is possible to palpate the normal tubes ; they are then felt as thin, 
round cords which roll between the examining fingers. 

The normal ovaries are palpated with difficulty, and are recog- 
nized by their position, size, form, and sensitiveness. The ovarian 
ligament is seldom felt. 

The pelvic peritoneum and cellular tissue should be explored as 
far as possible to discover undue sensitiveness, cicatricial contrac- 
tions, inflammatory exudates, tumor formations, and collections of 
blood. 

The rectum on its anterior wall may be explored through the 
vagina and something learned of its sensitiveness, inflammatory 
infiltrations, foreign growths, and fistulous openings. More satis- 
factory is the rectovaginal method of examination. 

The base of the bladder may be palpated through the anterior 
vaginal wall. Tumors, calculi, inflammatory infiltrations, new- 
growths, and tenderness from whatever cause can be determined 
with some degree of satisfaction. 

A rough estimate of the capacity and deformity of the bony 
pelvis can be made by the combined method. 

The ab domino-vaginal examination is of greatest service in the 
differential diagnosis of pelvic tumors. By the combined method 
their size, form, consistency, rate of growth, relative position, 
mobility, and connection with other structures are determined. 
When the tumor is large and in the abdominal cavity the method 
of Schultze may be employed with advantage. In addition to the 
customary bimanual examination an assistant draws the abdominal 
tumor upward while contraction is made upon the cervix with a 
vulsella forceps. (See Plate X.) 

The tumor may so closely press upon the uterus or be so closely 
adherent to it that a line of distinction between the two cannot be 

5 



QQ GENERAL DIAGNOSIS. 

recognized by the examining finger. The variations -in consistency 
and form, together with the use of the uterine sound, may deter- 
mine the relations. Swellings of the tubes and ovaries are at first 
to be differentiated from the uterus j but later, as they increase in 
size and become displaced behind or to the side of the uterus, they 
may be distinguished with difficulty. Likewise pelvic exudates 
may intimately blend with the uterus. Frequently bodies appar- 
ently immovable in one position may be movable in another. 

Examination under narcosis has many advantages. Kelly lays 
down the following rules for the use of anaesthesia in the diagnosis 
of diseases of women : 

1. Where doubt exists after the ordinary bimanual examination. 

2. Where a patient comes to a specialist after having had treat- 
ment for a long time at other hands without improvement. 

3. In all cases of pelvic peritonitis involving one or both ovaries 
or tubes without producing any gross tumor, when the use of the 
anaesthetic is to find out the extent of the disease. 

4. Always in unmarried women. 

Nitrous oxide will serve admirably in the majority of cases. 
When the examination must be prolonged, as in the use of the 
cystoscope or curette, either chloroform or ether should be used. 

It should be a rule to which there are no exceptions, that after the 
patient is asleep and before the operation is begun a thorough bimanual 
examination should be made. 

Under anaesthesia a higher reach may be gained by invaginating 
the pelvic floor. This is accomplished by making firm pressure upon 
the vulva and perineum with the examining hand. In so doing a 
gain of one to two and a half inches may be made. Additional 
pressure may be made by supporting the elbow of the examining 
arm against the hip and throwing the weight of the body against 
the arm. 

Digital Examination of the Rectum. In point of efficacy, 
digital examination of the rectum and, through the rectum, of the 
pelvic structures ranks next to the vaginal method, and in some 
conditions is to be preferred. 

(a) The Simple Rectal Touch. When for any reason a digital 
examination of the vulva cannot be made, the internal genital 
organs must be examined per rectum. Such conditions are a con- 
genital or acquired absence of the vagina, a narrow, shallow vagina, 
inversion of the uterus, and vaginismus. A rectal examination is 



EXAMINATION OF THE INTERNAL GENITALS. 



67 



of special advantage not only when the vaginal examination is 
precluded, but in all lesions in the rectovaginal space lying on the 
posterior pelvic wall. 

The position of the patient should be the lithotomy, knee-elbow, 
or the Sims. One or two fingers and, under anaesthesia, the whole 
hand may be used. In passing the finger into the rectum the 
tonicity of the sphincter is noted. Fissures, polyps, hemorrhoids, 



Fig. 10. 




Abdomi no-rectal examination. 

and new formations are detected. Through the anterior wall of 
the rectum is felt the posterior vaginal wall, the cervix, and part 
or all of the posterior surface of the uterus ; the base of the broad 
ligaments, frequently the tubes and ovaries when enlarged and 
prolapsed, and the uterosacral ligaments. Through the posterior 
wall of the rectum is felt the sacrum and coccyx. Because of the 
thinner and more distensible bowel wall the structures occupying 
the posterior segment of the uterus are more easily reached than 



68 



GENERAL DIAGNOSIS. 



they are through the posterior vaginal vault. The cervix project- 
ing backward is not to be mistaken for the body of the uterus. 

(b) AMomino -rectal examination (bimanual) is a method carried 
out in general as is the abdomino-vaginal examination. In virgins 
with an intact hymen it is the method of choice. All conditions 
recognized by a simple vaginal examination are more clearly pal- 
pated by the combined method. 



Fig. 11. 




Rectal examination with traction upou the cervix by a vulsella forceps. 

The examination may be embarrassed by coils of intestine wedged 
into. the cul-de-sac of Douglas. Where such difficulties exist and 
the bowels are not adherent, they may be displaced by placing the 
patient in the knee-chest position. A Sims speculum is inserted 
into the bowel, allowing the air to rush in and balloon the rectum, 
when the bowel will fall forward out of the cul-de-sac. The 
patient is then placed in the dorsal position and the examination 
continued. 



EXAMINATION OF THE INTERNAL GENITALS. 



69 



Traction upon the uterus in the abdomino-rectal exam- 
ination by vulsella forceps will greatly facilitate the examination 
where the uterus lies either too far forward or too high to be readily 
reached by the finger in the rectum. At the same time pressure 
may be made from above downward and backward upon the uterus. 
The vulsella forceps are held by an assistant while the operator 
makes the examination. Ko great amount of force should be 
applied to the uterus for fear of tearing adhesions. 



Fig. 12. 




Abdomino-vagino-rectal examination. The right hand depresses the abdomen, the thumb 
of the left hand is inserted into the vagina, and the index ringer into the rectum. 



(c) Abdomino-vagino-rectal examinations are seldom called for. 
While effective, they are unpleasant to patient and physician. The 
finger should never be withdrawn from the vagina and inserted 
into the rectum without cleansing. 

Digital examination of the bladder, either simple or combined 
with vaginal and abdominal methods (abdomino-vesical, abdomino- 



70 



GENERAL DIAGNOSIS. 



vesicovaginal), will not be considered. The method has been 
replaced by other more efficient and less objectionable methods. 

Pelvimetry, It is seldom that pelvic measurements are taken 
of a gynecological case. This is but an evidence of the illogical 
separation of obstetrics and gynecology. Not a few of the pelvic 

Fig. 13. 




Vesicorectal examination. A sound is passed into the bladder and the index finger into 
the rectum. In this manner the presence or absence of the uterus is determined. 

lesions are the result of deformities of the bony pelvis. For a 
detailed description of the deformities of the pelvis and their meas- 
urements, see text-books on obstetrics. For practical purposes the 
measurements between the anterior-superior spines of the ilium, 
between the trochanters, between the widest points in the crest of 
the ilium, and Baudelocque's diameters are all that are required. 



CHAPTER VIII. 

THE VAGINAL SPECULUM. 

For direct inspection of the vagina the speculum is used both in 
diagnosis and treatment. For diagnostic purposes it has a limited 
field of usefulness ; digital exploration will alone serve the purpose 
in a large proportion of cases. 



Fig 




Sims' duck-bill speculum. 



Fig. 15. 




Sims' vaginal depressor. 

The lithotomy position is the one of choice. The rectum and 
bladder must be emptied. Before introducing the speculum a 
digital examination of the vagina should be made to locate the 
cervix for the purpose of knowing the proper direction in which"to 
direct the speculum in exposing the cervix. 

The varieties of specula in common use are the Sims, Simons, 
bivalve, and tubular. 

Sims' speculum is used with best advantage in the lateral position 
of Sims. The vaginal outlet is spread open by the thumb and 
index finger of the left hand, while the right hand introduces the 



72 



GENERAL DIAGNOSIS. 



speculum. The blade is passed between the fingers spreading the 
vulva, and is allowed to glide over the perineum to the vault of the 
vagina. With the placing of the speculum the air rushes into the 



Fig. 16. 



J 



Emmet's tenaculum. 
Fig. 17. 




Bozeman's specula. 



THE VAGINAL SPECULUM. 73 

vagina and balloons it. In this manner a direct inspection of the 
vaginal mucosa is made possible. Firm and steady traction is made 
backward upon the perineum in exposing the cervix. The Sims 
speculum was originally used in the knee-elbow position, but is now 
almost invariably used in the Sims or left lateral posture. 

When the vagina is deep and the walls relaxed, in addition to 
the speculum, it is essential to use some sort of a depressor with 
which to expose the cervix by holding the walls of the vagina apart. 

When the cervix is directed backward and is not readily exposed 
to view, it may be hooked by a tenaculum and drawn forward. 
Such manipulations must only be carried out under the guidance 
of the eye or finger, for fear of hooking the vaginal wall instead of 
the cervix. 

Simons' speculum is a device not unlike that of Sims, having a 
single spoon instead of two. It has an advantage over Sims' 
speculum in that there is no second handle to interfere with the 
manipulation of the instrument. 

A combination of spoons of various shapes and sizes adjusted to 
separate handles was devised by Bozeman and others (Fig. 17). 

For the purpose of exposing the cervix the lateral walls of the 
vagina may require retraction. 

The bivalve speculum (Fig. 19) is in general use, though inferior 
in every respect to the Sims and Simons. Cusco's lateral modifi- 
cation is simple and easily manipulated. 

The instrument consists of two blades, taking the forui of 
a beak. The articulated outer end is manipulated by a screw 
which spreads the valves to an acute angle. The instrument is 
closed and inserted by its smaller diameter, and when inserted 
the instrument is turned so that the screw points toward the 
perineum. As the blades are separated they tend to distend 
the vagina, and the cervix engages between the blades. The 
great objection to this instrument is that the anterior and pos- 
terior walls of the vagina are obscured by the blades, and the trac- 
tion upon the vaginal walls separates the lips of the cervix to an 
unnatural degree. The one great advantage is the fact that it is a 
self-retaining speculum, requiring no assistant to hold it. 

In withdrawing the instrument care must be exercised for fear 
of catching folds of the mucous membrane ; the instrument must 
be withdrawn slowly and the screw gradually loosened as the 
speculum is retracted. 



74 



GENERAL DIAGNOSIS. 



The tubular speculum (Fig. 20) is seldom used. It is made of 
metal, wood, celluloid, glass, or vulcanite. It may be introduced 
in the lithotomy, knee-chest, or Sims position. It can only expose 
the cervix, and this is done with difficulty. 



Fig. 18. 




Pean's vaginal retractor. 



Fig. 19. 




Cusco's vaginal speculum. 

The self-retaiuing speculum (Fig. 21), composed of a spoon-like 
blade and a weighted handle, will be found of the greatest service 
in making exploratory curettage and in excising pieces from the 
cervix. Currier's weighted self-retaining speculum with two 
adjustable blades is an admirable device. 



THE VAGINAL SPECULUM. 



75 



Too much emphasis cannot be placed upon the necessity of sur- 
gical cleanliness in the use of vaginal specula. Some operators 
who scrupulously sterilize all instruments intended to be introduced 



Fig. 20. 




Ferguson's tubular speculum. 
Fig. 21. 




Currier's weighted speculum. 



into the uterus carelessly use a speculum after little or no cleansing. 
Gonorrheal infection is frequently transmitted in this manner. To 
fail to sterilize the vaginal speculum before using is criminal 
negligence. 



CHAPTER IX. 



THE VULSELLA. 

Traction upon the cervix is made with the vulsella forceps. 
When the uterus and its attachments are in a normal position 
the cervix can be drawn almost to the vulvar outlet. Little or no 
pain is caused by the grasp of the forceps upon the cervix. 

A vaginal speculum need not necessarily be used in grasping the 
cervix with the vulsella forceps ; the finger may be used as a 
guide. 

As an aid to diagnosis the vulsella forceps are used to make 
traction upon the uterus, bringing it and adjoining structures within 
easier reach of the examining finger in the vagina or rectum. 

Fig. 22. 




Pozzi's tenaculum forceps. 

In determining the relation of large tumors and swellings to the 
uterus, it is of advantage to steady the uterus by making traction 
downward upon the cervix. The forceps are held by an assistant 
while the examiner manipulates the tumor. If tumor and uterus 
move together there must be an intimate connection between the 
two. 

In differentiating an erosion from an eversion of the cervix the 
two lips of the cervix are grasped by the vulsella forceps and 
the lacerated edges approximated. If the red surface disappears 
an eversion is diagnosed ; if there still remains a red zone about 
the external os an erosion must be present. 



THE VULSELLA. 77 

In removing sections from the cervix for diagnostic purposes the 
cervix is grasped by the vulsella forceps. 

Forcible traction upon the cervix is not without danger. It is 
possible to rupture the peritoneum and to tear through adhesions. 
Acute inflammatory lesions of the pelvis are absolute contraindi- 
cations for the use of the vulsella forceps lest the inflammation 
be excited to further extension. In the pregnant uterus severe 
hemorrhage may be brought on by the application of the forceps. 

In removing the vulsella care is to be exercised for fear of injur- 
ing the cervix or wounding the patient. Superficial sutures of cat- 
gut or a vaginal pack with iodoform gauze may be placed if hemor- 
rhage is severe. 



CHAPTER X. 

UTERINE DILATORS. 

For the purpose of exploring the uterine cavity with the finger 
and curette the cervix must be dilated. Hegar's or Kelley's 
dilators are recommended for general use. By them the cervix is 
symmetrically dilated, with a minimum amount of trauma. 

Fig. 23. 




Hegar's uterine dilators. 



UTERINE DILATORS. 



79 



Fig. 24. 



Fig. 25. 





Ellinger's dilator. 



Goodell's dilator. 



80 



GENERAL DIAGNOSIS. 



cervix. 



The vaginal speculum may or may not be used to expose the 
The anterior lip of the cervix is grasped by a vulsella 
forceps. The dilators are sterilized by boiling, and lubricated 
with sterilized glycerin or boroglycerin. Beginning with a size 
that can be easily passed through the cervical canal, one after 
another of the sounds is passed until the cervix will admit the 
index finger. 

The utmost care must be exercised in passing the dilators for fear 
of losing control of the instrument and accidentally forcing it 
through the uterine wall. To eliminate this danger the depth and 
direction of the uterus should first be ascertained by the sound. 
The dilators are then grasped by the thumb and index finger at a 
point about one inch short of the length of the uterus. 



Fig. 26. 



Fig. 27. 



Fig. 28. 



Sea tangle tent. 



Sponge tent. 




Tupelo tent. 



Instruments of divulsion, such as Palmer's, GoodelPs, and Ellin- 
ger's, are commonly used in America. Only moderate force should 
be applied in dilating with these instruments for fear of tearing the 
cervix. They do not find favor in Europe. 

Tents are seldom used of late. They are not only slow and 
uncertain in their action, but are a source of danger from infection. 
They are made of sea tangle, sponge, and tupelo. A detailed 
account of their manner of insertion and use is to be found in text- 
books on gynecology. 



UTERINE DILATORS. 81 

Where great resistance is offered to the dilators, a unilateral or 
bilateral incision in the cervix may be made. Digital dilatation of 
the cervix is sometimes possible shortly after abortion or full-time 
labor. By first inserting the little finger, then the index, and, 
lastly, the middle finger, the cervical canal may be safely and 
efficiently dilated. 



CHAPTER XI. 

THE UTERINE SOUND. 

iETius speaks of using the sound to measure the length of the 
vagina. Sir James Y. Simpson introduced the modern sound as 
a material aid in the diagnosis of lesions involving the uterus. 
Simpson does not deny that the sound was used for exploration and 
measurements of the uterus long before his time. Certain it is that 
Wierus used the sound for like purposes as early as 1637. Begin- 
ning with the indorsement of Simpson and up to the present time 
the sound has been used too freely and not without danger. Since 
the bimanual method of examination has been largely practised the 
use of the sound has been materially restricted. It is seldom 
necessary to pass the sound in the consultation room. The bimanual 
examination will usually suffice. 

In the construction of a uterine sound there are certain require- 
ments. The instrument should be made of a flexible metal, prefer- 
ably of copper, and nickel plated ; the distal end should be rounded 
and knob-like ; the hands should be flat and grooved on one side 
only. Beginning two and one-half inches from the distal end the 
sound should be graduated every half inch for the purpose of 
measuring the depth of the uterine cavity. 

Preliminary Procedures. Before the sound is passed certain 
precautionary measures are necessary. First, there must be sur- 
gical cleanliness in the preparation of the field of operation, the 
instruments, and the hands of the operator. Second, a bimanual 
examination should be made to determine, if possible, the position 
of the uterus. By adhering to these preliminary precautions the 
dangers of infection and perforation are minimized. The most 
convenient position is the lithotomy, though it is possible to 
introduce the sound with the patient in the lateral or knee-chest 
position. 

Indications for the Use of the Sound in Diagnosis. 1. The 
depth of the uterine cavity is accurately measured by the sound. 
Its average normal depth is two and a half inches in a nullipara of 
mature years, and this is increased about one-half inch in multipara. 



THE UTERINE SOUND. 



83 



Fig. 29. 




(a) The depth of the uterine cavity is lessened in acquired and con- 
genital atrophy, atresia of the uterus, inversion of the fundus, and 
in new formations encroaching upon the cavity of the uterus. 

(b) The depth of the uterine cavity 
is increased in subinvolution, elonga- 
tion of the cervix, endometritis, me- 
tritis, and new-growths of the uterus. 

2. The direction of the uterine canal 
is often changed from the normal 
by new-growths in and about the 
uterus, by senile involution, by in- 
flammatory contraction, and by 
displacements of the uterus from 
whatever cause. As stated under 
preliminary precautions, it is always 
wise to precede the passage of the 
sound by a preliminary bimanual 
examination. If the relation of the 
body to the cervix is determined, 
the sound is curved at the proper 
angle before it is introduced. By 
so doing there is less dauger of punc- 
turing the uterus. 

3. Stenosis and atresia of the uterine 
canal are definitely determined by 
the sound. Apparent stenosis at 
the point of flexion is often made to 
disappear by traction upon the cer- 
vix with a vulsella forceps. 

4. Irregularities of the mucosa, if 
not too small and soft, may be de- 
tected by the sound. Such irregulari- 
ties are submucous fibroids, polyps, 
malignant growths, and retained 
placental tissue. When possible to 
use the finger it is always preferred 
to the sound. 

5. The Thickness of the Uterine Wall. By passing the sound 
into the uterus and with one hand over the abdomen, the fingers of 
the other hand in the rectum, it is possible under favorable con- 



Simpson's graduated sound. 



84 



GENERAL DIAGNOSIS. 



ditions to make a fair estimate of the thickness of the uterine 
wall. 

Contraindications to the Use of the Sound. 1. Menstruation. 
Though not an absolute contraindication, it is better to delay the 
procedure until the intermenstrual period. 

2. Pregnancy is an absolute contraindication for the passage of the 
sound. While the sound has been passed into a gravid uterus 
without interrupting pregnancy, it is never justifiable to pass the 
sound where there is a possibility of pregnancy. 

3. Malignant growths, while not an absolute contraindication, are 
to be regarded as a source of danger and demand very cautious use 
of the sound for fear of exciting hemorrhage. 

4. Acute pelvic inflammation is a contraindication for the use of 
the sound as well as all manipulation of the pelvic viscera. 

DANGERS INVOLVED IN THE USE OF THE SOUND. 

1. Infection of the uterus may be caused either by an unclean 
instrument or by carrying the infection from the lower genital tract. 
Forcible and careless manipulations injure the delicate mucosa, pro- 



FlG. 30. 




First step: passing sound; patient in dorsal position without speculum; point of sound is 
guided along palmar surface of left index finger to os externum. (Dudley). 



THE UTERINE SOUND. 85 

ducing an atrium for infection. Because of the danger of infection 
the custom of passing the sound in the routine office practice is 
condemned. 

2. Perforation of the uterus is an accident that may happen to the 
most cautious operator. The uterine wall may be so soft as to 
offer no perceptible resistance to the passage of the sound into the 
peritoneal cavity. Such softening may be due to infection and to 
malignant infiltration. 

Fig. 31. 




Second step : passing sound ; patient in dorsal position without speculum. As sound passes 
from os externum to fundus, index finger is moved from os externum to posterior vaginal 
fornix. (Dudley). 

3. Hemorrhage may be alarming in the case of malignant growths 
of the uterus, in hydatid mole, and in incomplete abortion. 

4. Pelvic inflammation may be occasioned by the passage of a 
sound into the uterus. This is seldom the case in the absence of a 
pre-existing infection. 

It is dangerous practice to test the mobility of the uterus by 
means of the sound. The bimanual examination with or without 
anaesthesia should afford all needed information with far less risk. 



CHAPTER XII. 

THE UTERINE CURETTE. 

The fact that the uterine curette is universally used speaks 
for its utility ; but, as with many of the great and useful things 
of life, it is equally capable of harm, in the hands of the incom- 
petent. 

The use and abuse of the uterine curette is a subject that should 
engage the careful consideration of the general practitioner far more 
than many of the more pretentious problems in the treatment of 
diseases of women, because the curette is the most used and the 
most abused of the armamentarium of the gynecologist, and, I 
might add, of the general practitioner. 

Let us briefly consider the indications for the use of the uterine 
curette in the diagnosis of the diseases of women. 



Fig. 32. 



mmmmmmemsssi 

Blake's curette. 
Pig. 33. 



m 

Boldt's double curette. 

The uterine curette in diagnosis may be used in any of the 
lesions within the uterine cavity and involving the endometrium. 

1. First in order of clinical importance and frequency is endo- 
metritis. An excessive menstrual flow and a so-called leucorrhoeal 
discharge from the uterus, together with a history of infection, 
generally suffice for a clinical diagnosis of endometritis ; but a 
positive diagnosis — one that amounts to a scientific certainty — can 
only be made by a microscopic examination of scrapings removed 
by the curette. All of the clinical signs of endometritis may be 
present without inflammatory changes in the endometrium, and, on 
the other hand, endometritis may be present to a marked degree in 
the absence of any clinical evidence. It is never justifiable to 



THE UTERINE CURETTE. 87 

curette the uterus for the purpose of differentiating between the 
various anatomical forms of endometritis, but rather to determine 
the fact of endometritis and to exlude other possible lesions, such 
as retained placental tissue and carcinoma. It is a matter of little 
concern whether we have to deal with a hypertrophic or hyper- 
plastic, a fungus, or a polypoid endometritis. It is the fact of 
the presence of endometritis and not of the particular anatomical 
variety that is of practical clinical importance. 

2. Retained products of conception may remain attached to the 
uterus for years, giving rise to hemorrhage and leucorrhcea, the 
cause of which can only be demonstrated by exploring the uterine 
cavity. In all such cases the finger, if possible, should be used in 
locating and removing the retained foetal tissue. Shortly after 
abortion and labor curetting is rarely justifiable because of the 
dangers involved. 

3. The firm, rounded bulging of a submucous fibroid is sometimes 
demonstrated by means of the curette. 

4. Malignant growths of the endometrium can only be diagnosed 
in the early stage by microscopic examination of scrapings. There 
may be no symptoms, or merely those common to endometritis, and 
this is even possible in cases far advanced. In my personal expe- 
rience the systematic examination of uterine scrapings has frequently 
brought to light an unsuspected malignant growth, and that which 
has passed clinically for malignancy has been demonstrated to be 
endometritis or retained placental tissue. 

Syncytioma malignum — i. e., a malignant degeneration of 
placental tissue — is a rare finding, but because of its rapid spread 
and fatal issue an early diagnosis is imperative. When an unac- 
countable hemorrhage from the uterus occurs weeks or months 
after labor or abortion, and particularly after the expulsion of a 
hydatid mole, an exploratory curettage is demanded, and a micro- 
scopic examination should be made in view of the possibility of 
finding malignant changes in the placental remains. 

There is no more important and certainly no more satisfactory 
procedure in all the range of diagnosis than the differential diag- 
nosis of uterine scrapings. A sharp line cannot always be drawn 
between the benign and the malignant, but in the hands of a com- 
petent observer such failures are unusual. 

In the diagnosis of ectopic pregnancy it is sometimes advisable to 
curette the uterus to determine the presence of decidual tissue. 



88 GENERAL DIAGNOSIS. 

Great caution must be exercised for fear of rupturing the gestation 
sac. 

Contraindications to the use of the curette are first of all 
menstruation. This is not an absolute contraindication, but it is 
seldom that the procedure cannot wait until the menstrual period is 
passed. 

2. Pregnancy. The possibility of pregnancy must be positively 
excluded. Where doubt exists after a thorough examination it is 
always well to await developments for a month or more. A good 
rule to follow is never to use the curette in cases of delayed men- 
struation where pregnancy is at all possible. 

3. Acute and subacute pelvic inflammations are contraindications, 
because of the danger of extending the infection. It is always wise 
to wait until the pelvic inflammation has subsided before curetting. 

Distended tubes and ovaries are liable to rupture. No harm 
will likely result if the contained matter is serum, but if pus 
escapes the consequences may be disastrous. 

The dangers involved in curettage are by no means trivial. 
The curette is a formidable instrument, and curettage is not to be 
regarded as a minor operation and without danger. 

1. As with all operations, there is the risk of septic infection 
through the wounded surface. The liability to infection is not great 
when the uterus is firmly contracted ; but in the puerperal uterus, 
with large venous sinuses and possible infection already exist- 
ing therein, all the conditions are present favoring a wound in- 
fection. 

2. Hemorrhage is an unlooked-for complication, yet in puer- 
peral and malignant cases the loss of blood may be alarming and 
fatal. 

3. The danger of exciting an acute exacerbation of a pre-existing 
pelvic inflammation is always imminent. 

4. Perforation of the uterus by the curette is an accident that may 
happen to the most skilled and cautious surgeon. I venture the 
assertion that not an operator of large experience has escaped this 
misfortune. We are not to be assured by the statements frequently 
made that the perforation is of little consequence. In a puerperal 
infected uterus the uterine wall may offer no more resistance to the 
curette than would blotting-paper ; the instrument passes through 
the wall apparently meeting no resistance. In such cases our only 
safeguard lies in discarding the curette, both the dull and the sharp. 



THE UTERINE CURETTE. 89 

The fingers, placental forceps, and douche are all sufficient, save in 
very exceptional cases. Not only is the finger less likely to per- 
forate the uterus, but by the finger the placental site is located and 
the adherent placenta removed, leaving the remaining uterine sur- 
face intact, as it should be. Nature has thrown out a barrier in the 
decidua in the form of leucocytes or phagocytes, the so-called " pro- 
tective zone/' that will resist the invasion of micro-organisms if it 
is possible for anything to do so. The curette would but tear away 
this protective wall and allow a direct invasion of the venous 
sinuses by the septic organisms. 

5. The removal of the decidua down to the musculature is a pos- 
sible danger when the curette is used. With the finger this accident 
will not occur. From the decidua the new endometrium is regen- 
erated, and if completely scraped away there will be left in its place 
a permanent scar surface, rendering the woman sterile and a 
sufferer. 

The same result, though to a lesser degree, may follow too vigor- 
ous scraping of the non-puerperal uterus. The grating of the 
instrument is a sign that the mucosa is removed down to the deeper 
and firmer layer, and it is time to stop lest the entire mucosa be 
removed. 

The following is an outline of the technic of curettage : 

1. Anaesthesia, preferably chloroform. 

2. Sterilization of the vulva and vagina. 

3. Dilatation of the cervix with Hegar's bougies or an instrument 
of divulsion. 

4. Introducing a curette to one of the uterine horns and de- 
liberately sweeping downward as far as the internal os. Passing 
by successive sweeps along the posterior wall to the opposite horn, 
then to the side and in front to the original point of attack, making 
sure that no furrows or patches are left by again going over the 
surface in a similar manner. 

5. Irrigating the uterus with salt solution. As a routine prac- 
tice I would recommend swabbing the uterus with full strength 
formalin. 

6. No uterine pack is recommended unless the uterus is relaxed 
and bleeding freely. A sterilized vaginal tampon may be inserted 
against the cervix for twenty-four hours, then removed, and 1 per 
cent, lysol douches or formalin, 1 : 1000, may be given daily for a 
week. 



90 GENERAL DIAGNOSIS. 

7. Rest in bed should be enjoined for a period of four or more 
days. 

8. No escharotics should be used. The sharp curette should be 
used in all cases, with the exception of a puerperal uterus, when a 
dull curette is employed after more conservative methods have 
failed. (See Plates XI., XII., and XIII.) 



PLATE XL 

Fig. 1. 




Curettage. First step: dorsal position. Cervix exposed by perineal retractor in right hand 
of assistant. Uterus drawn down by vulsella forceps held by left hand of assistant. Dilatation 
by graduated bougies held in right hand of operator. 

Fig. 2. 




Curettage. First step : dorsal position. Cervix exposed by perineal retractor in right hand 
of nurse. Uterus drawn down by vulsella forceps in left hand of assistant. Dilatation begun 
by small dilator in right hand of operator. (Dudley.) 



PLATE XII. 

Fig. 1. 




Curettage. Second step : dorsal position. Cervix exposed by perineal retractor in right hand 
of nurse. Uterus drawn down by vulsella forceps in left hand of assistant. Dilatation com- 
pleted by Wathen dilator in hands of operator. (Dudley.) 



Fig. 2. 




Curettage. Third step : dorsal position. Perineum retracted by two fingers of operator's left 
hand. Uterus drawn down by vulsella forceps in left hand of assistant. Endometrium 
curetted by sharp curette in operator's right hand. (Dudley.) 



PLATE XIII 

Fig. 1. 




Curettage. Fourth step : dorsal position. Perineum retracted by two fingers of operator's 
left hand. Uterus drawn down by vulsella forceps in left hand of assistant. Endometrium 
irrigated by canula inserted into rubber tube in operator's right hand. Figs. A and B show 
a fountain syringe attached to a towel by means ot pressure forceps. The towel may be fas- 
tened to a curtain or other hanging by means of safety-pins. The fountain syringe may be used 
instead of the funnel. (Dudley.) 

Fig. 2. 




Curettage. Final step : dorsal position. Perineum retracted by Simon retractor in right 
hand of nurse. Uterus drawn down by vulsella forceps in left hand of assistant. Endo- 
metrium disinfected by cotton wound on Emmet's dressing forceps and saturated with desired 
disinfectant. Application made by right hand of operator. (Dudley.) 



CHAPTER XIII. 

MICEOSCOPIC EXAMINATION OF SCRAPINGS AND EXCISED 

PIECES. 

The microscope is indispensable in the diagnosis of diseases of 
women. The microscopic examination of scrapings and excised 
pieces constitutes one of the most important and gratifying means 
of determining the character of lesions involving the cervix and 
endometrium. 

The bimanual examination will alone determine many of the 
affections of the pelvic viscera ; inspection of the vagina and vaginal 
portion of the cervix through a speculum will afford much informa- 
tion ; direct palpation of the cervical canal and cavity of the uterus 
will add much to our knowledge of the extent and character of the 
lesions involving these surfaces ; the clinical symptoms are impor- 
tant in the consideration ; but a positive diagnosis, one that admits 
of no reasonable doubt, is often reserved until a microscopic exam- 
ination of scrapings and excised pieces has been made. 

Very often the microscope serves to verify a clinical diagnosis, 
but in not a few cases a previously unsuspected condition is brought 
to light by a microscopic examination of scrapings from the endo- 
metrium and excised pieces from the vaginal portion of the cervix. 

The author does not claim that the microscope is an infallible 
means of making a diagnosis. In exceptional cases the diagnosis 
remains in question after all means — the microscope included — have 
been exhausted. 

REMOVAL OF UTERINE TISSUE FOR DIAGNOSTIC PURPOSES. 

In all cases, unless contraiudicated, a general anaesthetic is advis- 
able. Cocaine may be used as a local anaesthetic in excising pieces 
from the cervix. AY hen the tissue is soft and friable, as in car- 
cinoma, no local or general anaesthetic may be required. 

It is not necessary to shave the vulva, but by scrubbing and 
douching the field of operation is made clean. 



92 GENERAL DIAGNOSIS. 

The position assumed by the patient may be the Sims or lith- 
otomy. If the former, the Sims or Simons speculum is used ; if 
the latter, the Simons or self-retaining speculum is preferred. 
The self-retaining speculum is especially advantageous because no 
assistant is needed. 

Test Excision from the Cervix. After grasping the anterior 
lip of the cervix by vulsella forceps, a small wedge is cut from 
the cervix by angular scissors. In selecting a portion for excision 
an effort should be made to include in the removed piece a part of 
healthy together with diseased tissue for the purpose of studying 
the transition stages. 

Hemorrhage is to be controlled by a gauze pack, or, when neces- 
sary, by the placing of absorbable sutures. 

Test Curettage of the Uterus. The cervix is dilated sufficiently 
to admit a moderate-sized curette. The instrument is passed under 
control of the eye by the aid of a Sims or Simons speculum. The 
patient is in the Sims or lithotomy position. In order that no 
portion of the endometrium escape the curette, the uterus should 
be scraped systematically and thoroughly, beginning at one horn 
and sweeping deliberately down to the internal os, passing in this 
manner over the entire inner surface of the uterus, taking care that 
no portion of the endometrium be missed. Before the blood has time 
to firmly coagulate the scrapings should be removed to a 4 per cent, 
solution of formalin. Allowing them to lie long in water causes 
maceration. All particles in the scrapings are to be carefully pre- 
served, so that if necessary the entire specimen may be examined. 

Frozen Specimens of Excised Pieces and Scrapings. Where 
an immediate diagnosis is required the freezing method may be 
employed with fairly satisfactory results. It occasionally happens 
that the examination of excised pieces and scrapings will determine 
the question of a more radical procedure. If by reason of expe- 
diency or added risk from a second anaesthetic it becomes necessary 
to proceed without delay, frozen sections may be prepared and 
diagnosed while the patient is being prepared for a radical opera- 
tion. Not more than twenty minutes are required for the exam- 
ination. 

The following is the method employed in Johns Hopkins Hospital 
by Cullen : 

(a) Place the frozen section in 5 per cent, aqueous solution of 
formalin for from three to five minutes. 



MICROSCOPIC EXAMINATION OF SCRAPINGS. 



93 



(b) Leave in 50 per cent, alcohol one minute. 

(c) In absolute alcohol one minute. 

(d) Wash out in water. 

(e) Stain in hseniatoxylin two minutes. 
(/) Decolorize in acid alcohol. 

(g) Rinse in water. 



Fig 




Bardeen C0 2 freezing microtome. 

This microtome is an improved pattern after designs by Professor C. R. Bardeen, ot Johns 
Hopkins University, and is a most excellent instrument for regular pathological and other 
demonstrations. It is indispensable for clinical work where stained sections of morbid tissues 
are required within a few minutes of the beginning of an operation in order that the surgeon 
may determine his mode of procedure. 

It freezes almost instantaneously regardless of room temperature or humidity and at very 
small expense. The temperature of the object to be frozen is, within limits, under the control 
of the operator. 

The freezing chamber contains a spiral passage through which the expanding C0 2 passes, 
securing the maximum freezing power. 

The knife slides on glass guides. The finest feed is twenty microns. The microtome may 
be attached directly to a COo cylinder. 



94 



GENERAL DIAGNOSIS. 



(h) Stain with eosin. 

(i) Transfer to 95 per cent, alcohol. 

(j) Pass through absolute alcohol, then through either creosote 
or oil of cloves, and mount in Canada balsam. 

While the freezing method has an important place in connection 
with the operating room, the sections are not overly satisfactory, for 
the reason that only small sections can be made and differentiating 
stains cannot be used. Where an immediate diagnosis is not 
required (and this is true in the majority of instances) the celloidin 
or paraffin methods are preferred. 



Fig. 35. 




Ether or rhigolene freezing attachment. 
This attachment consists of a cyndrical freezing stage upon which the object to be frozen is 
placed and against which a very fine spray of ether or rhigolene as desired is projected by a 
delicate atomizer operated by the bulb air-pump shown in the illustration. The rapid evapora- 
tion of the fluid abstracts sufficient heat from the object to freeze it in a short time. There is 
always, however, an excess of fluid which does not evaporate, and this is drained back into a 
bottle and used again. This freezer is applicable to the automatic laboratory, medium 
laboratory, student, table, and demonstration microtomes. 



MICROSCOPIC EXAMINATION OF SCRAPINGS. 95 



FIXING THE SPECIMENS. 

Zenker's fluid (Miiller's fluid, 100 per cent. ; bichloride, 5 per 
cent., and, shortly before using, the addition of 5 per cent, of glacial 
acetic acid) is an excellent fixing fluid, preserving the blood in its 
natural color. After fixing in Zenker's for twenty-four hours the 
section is placed in cold running water for twenty -four hours or in 
a weak iodine solution for a like time. The section is then ready 
for hardening in alcohol. No better fixing fluid can be used where 
time will permit. It is often well to place the entire uterus in 
Zenker's fluid for a week or more before cutting sections from it. 

Alcohol as a fixing agent is objectionable because of the shrinking 
of the tissues. Where it is desired to examine for micro-organisms 
alcohol is of special value. 

Formalin may be used in a 2 to 4 per cent, solution. It is 
objected to because of the difficulty in cutting the musculature. 

HARDENING AND EMBEDDING. 

When it is desired to prepare the section hurriedly, a small piece 
is placed immediately in absolute alcohol and changed three or four 
times in twenty-four to thirty-six hours, when it is ready for 
embedding. 

When an additional day or two can be taken better sections are 
made by running the pieces through successive strengths of alcohol 
and changing every two to twelve hours through 70, 80, and 90 per 
cent, and absolute alcohol. 

It is now necessary to embed the section in a substance which 
will permeate the tissue, filling up all spaces and giving support to 
the section while being cut and mounted. 

The embedding of a specimen in celloidin follows upon the hard- 
ening process. For general purposes the celloidin method is pre- 
ferred. From absolute alcohol the section is placed in equal parts 
of sulphuric ether and absolute alcohol from six to twenty-four 
hours, depending upon the size of the section. Next the section is 
changed to a dilute solution of celloidin in ether for from six to 
twenty-four hours ; it is placed in a thick solution of celloidin in 
ether for an equal time, when it is ready to mount upon a cork for 
sectioning. 



96 



GENERAL DIAGNOSIS. 



After blocking the specimen on wood or cork it is allowed to 
fix firmly in the open air or under a bell-jar, and is then placed in 
70 per cent, alcohol for an hour or more. The section is now ready 
for cutting and mounting. 

The embedding of specimens in paraffin is an excellent method for 
general laboratory purposes, but is somewhat complicated for 
private laboratory use. When the tissues are soft and small, as in 
scrapings, ideal sections are prepared by this method, For serial 
sections no other method can be employed. After thoroughly 
dehydrating the tissue the specimen is immersed in a solution of 
zylol and paraffin, or in chloroform and paraffin, from two to twenty- 
four hours, and is kept at a uniform temperature of 37° C. Next 
the specimen is immersed in melted paraffin for a like time and 

Fig. 36. 




Student microtome. 

The student microtome is intended for individual and laboratory use where a reliable 
mechanical microtome at small cost is required. It is extremely simple, yet very accurate in 
construction. This is one of the few models which have remained practically xmchanged, 
showing that it is adapted for its work. 

The stand is one solid piece of metal. The knife block is as heavy as is consistent with the 
size of the instrument. The feed arrangement is carried in a metal stirrup attached perma- 
nently to the front of the stand and consists of an accurately cut micrometer screw having 
pitch of 0.5 mm., with graduated head divided to 100 parts, each graduation, therefore, having 
a value of 5 microns. The object clamp is adjustable in two planes and can be set for 
paraffin or celloidin cutting. 



MICROSCOPIC EXAMINATION OF SCRAPINGS. 



97 



kept at a temperature of 48° to 50° C. It is then removed to a 
cool place and is quickly solidified in the paraffin, after which it is 
blocked out Avith a knife and mounted on a cork for cutting. 



METHOD OF STAINING AND MOUNTING SECTIONS. 

Celloidin Sections. For all practical purposes the hsematoxylin- 
eosin stain is most satisfactory. After cutting the sections and 
immersing them in water for a few moments, the following method 
is adopted : 



Fig. 3 




Lines of incision in opening the uterus after hysterectomy. 

1. Stain in hematoxylin one to two miuutes. 

2. Decolorize in acid alcohol. 

3. Immerse in weak ammonium water until the blue color 
returns. 

4. Immerse in water to remove the ammonium. 

5. Counterstain in eosin from ten to thirty seconds. 



98 



GENERAL DIAGNOSIS. 



6. Immerse in 75 per cent, alcohol two minutes. 

7. Absolute alcohol one minute. 

8. Clear in creosote or oil of cloves. 

9. Mount in Canada balsam. 

Paraffin Sections. After cutting the sections they are carefully 
transferred to a shallow basin of warm water, on which they spread 
in thin ribbons. The water must not be hot enough to melt the 
paraffin, but merely sufficiently so to unfold the sections and spread 



Fig. 38. 




The uterine cavity exposed. 



them out smoothly. A glass slide is held underneath the sections, 
and they are made to float upon the slide. The slide is then with- 
drawn from the water, the water drained off, and is then placed for 
several hours on the top of an oven or radiator, where the moisture 
is thoroughly driven from the slide and the section firmly fixed. 
The paraffin is dissolved in zylol or chloroform (by which the sec- 
tion is " cleared "), and from this point on the staining is carried out 
in the usual manner. 



MICROSCOPIC EXAMINATION OF SCRAPINGS. 99 



INSPECTION OF THE UTERUS AFTER REMOVAL. 

In order that a satisfactory examination may be made of the 
uterus after its removal, the operator should handle and mutilate the 
specimen as little as possible. Introduction of swabs, probes, and 
curettes injure the endometrium and lead to false observations. 
Fig. 37 shows the method of opening the uterus. The body of the 
uterus is grasped by the left hand. Two incisions are made, as 
shown in Fig. 38, and the uterus is spread open in such a manner 
that the entire mucosa will be exposed. Before small sections are 
removed it is always Avell to fix the uterus in Zenker's fluid for 
several days. The structures are thereby least disturbed in their 
relations. 

The color, consistency, outline, and measurements are all to be 
noted and recorded. Foreign growths and abnormalities are 
described in detail. 



CHAPTER XIV. 

EXPLORATOEY PUNCTUEES AND INCISIONS 

An exploratory puncture is not seldom resorted to for the purpose 
of completing the diagnosis. When conjoined examination fails to 
determine the nature of a pelvic tumor aspiration is an essential aid 
to the diagnosis. Collections of blood, pus, and serum in the tubes, 
ovaries, and pelvic tissues often cannot be diagnosed with certainty 
until the contents are procured either by aspiration or by incision. 
Furthermore, the character of the obtained fluid may not be recog- 
nized until submitted to a chemical, microscopic, and bacteriological 
examination. It is a growing conviction that an exploratory in- 
cision affords better results and is less dangerous than is aspiration. 
This is particularly true of abdominal explorations. 




Exploratory syringe. 



The instrument and field of operation must be rendered perfectly 
sterile. When surgical principles are carried out no harm should 
follow either procedure. Exploratory incisions are of value not 
only in determining the character of the contained fluids in the 
pelvis, but the procedure has a wide range of usefulness. Indeed, 
it may be truly said that every abdominal incision is in a sense 
exploratory. The abdominal surgeon very often encounters unsus- 
pected growths and adhesions, and, for this reason, one who is not 
master of any condition that may unexpectedly arise should not 
undertake to open the abdominal cavity. 



PLATE XIV. 




BREAST OF DARK BRUNETTE, NEAR TERM 
From Life ( Je^wett. ) 



PLATE XV. 



BREAST OF BLONDE IN LATER MONTHS OF PREGNANCY. 
From Life. (Jewett. ) 



THE DIAGNOSIS OF UTERINE PREGNANCY. 



103 



Value of the Sign. In a ivoman of the childbearing period, who 
has previously been regular, cessation of menstruation is a highly 
probable sign. 

2. Morning Sickness. Occurs commonly between the fourth 
and eighth weeks ; earlier and more frequent in primipara. 



Fig. 41. 




Breast of woman who has been pregnant, showing pigmented areola and position of gland. 

Dennis.) 

Fallacies : 

1. Diseases of the brain, kidney, and digestive tract. 

2. Uterine displacements. 

3. New-growths of the uterus and ovaries. 

Value of the Sign. Highly presumptive when associated, with 
amenorrhoea. 

3. Salivation. Rarely present after the fourth week, and is 
of no special value. 



104 SPECIAL DIAGNOSIS. 

4. Nervous Phenomena. 

1. Ringing in the ears — rarely present. 

2. Neuralgia — rarely present. 

3. Changes in disposition. 
Value of the Sign. Negative. 

5. Irritable bladder, due to the size and weight of the uterus. 
Value of the Sign. Negative. 

II. Objective Signs. 

1. Changes in the Mammary Glands. At the end of the 
fourth week the breasts tingle and enlarge ; at about the twelfth 
week there is pigmentation and enlargement of the areola, promi- 
nence of the glands of Montgomery, the nipples enlarge, become 
erectile and sensitive, veins stand out prominently under the skin, 
a secondary areola forms, linea albicantes are sometimes seen near 
the areola, and colostrum is secreted. 

Fallacies : 

1. Breasts may enlarge from pelvic tumors. 

2. Breasts may enlarge during menstruation. 

3. Prostitutes and multipara? may have a secretion of colostrum. 

4. Multiparas retain some of above signs, and little or no 

change may occur during pregnancy. 
Value of the Sign. Highly presumptive, and especially in young 
primiparce. 

2. Discoloration of the vulva and vagina may occur as 
early as the sixth week or as late as the eighth month. The 
structures soften and become blue in color from venous congestion. 
Discoloration varies in degree and in time of appearance. 

Fallacies : 

1. Frequently observed in fleshy women. 

2. Caused by all new formations and inflammatory swellings 

in the pelvis. 

3. May be due to portal congestion from diseases of the heart, 

lungs, liver, kidney, etc. 
Value of the Sign. Presumptive. 

3. Softening of the vaginal portion of the cervix 
generally begins at the fourth week, earlier in multiparas. It is 
due to passive congestion. The softening begins at the external os 
and extends upward. 



THE DIAGNOSIS OF UTERINE PREGNANCY. 105 

Fallacies : Same as for discoloration of the vulva and vagina. 
Value of the Sign. Highly presumptive. 

Fig. 42. 




Bimanual examination for compressibility of the isthmus at the sixth week. (Jewett.) 



Fig. 43 




Retroversion of a pregnant uterus, with fixation by adhesions binding the fundus to the 

rectum and sacrum. 



106 



SPECIAL DIAGNOSIS. 



4. Softening and Compressibility of the Lower Uterine 
Segment (Hegar's sign). Elicited by introducing one or two 
fingers into the posterior vaginal fornix and approximating the 
fingers of the hand over the abdomen as closely to the fingers in 
the vagina as possible. The lower uterine segment may be com- 
pressed to the thinness of paper. 

Hegar's sign may be elicited as early as the sixth week. The 
sign may be impossible of demonstration, because of the thickness 



Fig. 44. 




Anteversio-flexion of the pregnant uterus at the end of the third month of pregnancy. 



and rigidity of the abdominal wall. Rectal palpation will be of 
service in these cases. 

Value of the Sign. Very reliable, though not a positive sign of 
pregnancy. 

5. Leucorrhcea often begins early and persists throughout 
pregnancy. 

Value of the Sign. Negative. 



THE DIAGNOSIS OF UTERINE PREGNANCY. 107 

6. Changes in Position, Size, Form, and Consistency of 
the Uterus. 

a. Position : extreme anteversion. 

b. Size of child's head at end of third month. 

c. Form : increase in the antero-posterior diameter, becom- 

ing spherical at the end of the third month. 

d. Consistency : soft and elastic. 
Value of the Sign. Highly presumptive. 

There are no positive signs of pregnancy in the first trimester except 
seeing the foetal structures and decidua, but when two or more of the 
above-named presumptive or highly probable signs are present the diag- 
nosis of pregnancy amounts to a moral certainty. 

Second Trimester. 

I. Subjective Signs. 

1 . Cessation of Menstruation continues. 

2. Morning sickness rarely persists after the fourth to the 

fifth month. 

3. Salivation rarely continues. 

4. Nervous phenomena may increase. 

5. Bladder may be less irritable. 

6. Active Fcetal Movements. Time of occurrence, six- 

teenth to eighteenth week — earlier in multipara. Likened 
to the fluttering of a bird in the hand, and increases in 
force with time. 
Fallacies : 

1. Peristaltic movements of the bowel. 

2. Spasmodic contractions of the abdominal muscles. 

3. Movements of abdominal tumors. 

Value of the Sign. Presumptive. Of value in determining the 
date of confinement. Count forward twenty-three weeks in prim- 
ipara, twenty-four weeks in multipara. 

II. Objective Signs. 

1. Active Fcetal Movements. A certain sign of pregnancy 

when felt and heard by the physician. 

2. Passive Fcetal Movements (ballottement). Is first elicited 

about the sixteenth week. Ballottement may be : 



108 



SPECIAL DIAGNOSIS. 



(a) Internal. Hands are placed as in an abdomino- 
vaginal examination. With the hand on the abdo- 
men a sharp tap is given ; the foetal body is felt to 
bound and rebound. 

(6) External. The hand is placed flat upon one side of 
the abdomen, the opposite side is sharply tapped 
with the fingers of the other hand. 
Fallacies : 

1. Pedunculated tumors floating in ascitic fluid. 

2. Stone in the bladder. 

3. Floating kidney and spleen. 



r iG. 45. 




Internal ballottement, semirecumbent posture, at sixth month. (Jewett.) 

Value of the Sign. Positive in competent hands. 

3. Direct Palpation of the Foetus. 
Value of the Sign. Positive. 

4. Intermittent Uterine Contractions. The time of 

appearance is between the tenth and sixteenth week. The 
uterus becomes firmer and assumes a pear shape, then 
slowly relaxes. The intervals between contractions are five 
to twenty minutes. 
Fallacies : 

1. Contractions of the recti muscles. 



THE DIAGNOSIS OF UTERINE PREGNANCY. 109 

2. Contractions of soft fibroids. 

3. Intermittent uterine contractions in haBmatometra, pyometra, 

and hydrometra. 
Value of the Sign. Positive. 

5. Auscultation. 

1. Foetal Heart Tones. Heard in the fourteenth to the eigh- 

teenth weeks. The conditions governing the intensity of 
the heart tones are : 

a. Position of the foetus. Heart tones increased when 

the child's back presents. 

b. Position of the placenta. Heart tones decreased 

when auscultating through the placenta. 

c. Size of child. Heart tones strong in proportion to 

the development of the child. 

d. Thickness of the abdominal walls obscures the foetal 

heart tones. 

The heart tones resemble the tick-tack of a watch under a pillow. 
The frequency is 100 to 150 a minute. Temperature and exercise 
increase and uterine contractions slow the heart beat. 

Value of the Sign. Most reliable of all signs, not only showing the 
fact of pregnancy, but also the life of the foetus. 

2. Foetal Souffle. A soft, blowing sound synchronous with the 

foetal heart beat occurs in 14 to 16 per cent, of all cases. 
The sound is caused by the circulation in the cord, and is 
said to be due to an abnormally short cord or one that is 
twisted, knotted, or wound about the neck of the child. 
Value of the Sound. Positive when heard. 

3. Placental Souffle. A soft, blowing sound, synchronous with 

the maternal heart beat. The intensity is decreased dur- 
ing uterine contractions. The sound is not constant in 
rhythm or intensity, and is best heard on the left side of 
the uterus. The time when first heard is between the 
fourteenth and eighteenth week. 
Fallacies : 

a. Heard in vascular tumors of the pelvis. 

6. Gas in the mother's bowels. 

c. Murmurs in the arteries of the pelvis. 
Value of the Sign. Probable sign of pregnancy. 

6. Kate of Geowth of the Uterus. 

Value of the Sign. Positive in experienced hands. No other tumor 
grows so steadily and rapidly. 



HO SPECIAL DIAGNOSIS. 

7. Changes in Position, Size, Form, and Consistency of 
the Uterus. 

(a) Position — median. 

(6) Size. End of the third month, at the level of symphysis 
pubis. 
End of the fourth month, three finger-breadths 

above symphysis pubis. 
End of the fifth month, two-thirds the distance 

from the pubes to the umbilicus. 
End of sixth month, at the level of the umbilicus. 
(See Fig. 46.) 

(c) Form — globular. 

(d) Consistency — soft and elastic. 

Value of the Sign. Positive in experienced hands. 

Third Trimester. 

I. Subjective Signs. 

1. Cessation of Menstruation continues. 

2. Morning sickness rarely persists. 

3. Salivation rarely persists. 

4. Nervous phenomena may be increased. 

5. Active fcetal movements increase, and may seriously annoy 
the mother. 

II. Objective Signs. 

1. Active fcetal movements increased. 

2. Passive fcetal movements increased. 

3. Direct palpation of the fcetus usually accomplished 
with ease. 

4. Intermittent uterine contractions marked. 

5. Auscultation of fcetal heart, fcetal and uterine 
souffle increasingly distinct, 

6. The rate of growth of the uterus continues as in second 
trimester. 

7. Position of the uterus at the end of the seventh month 
is one-third the distance from the umbilicus to the ensiform car- 
tilage ; at the end of the eighth it is two-thirds the distance, and 
at full term it has dropped back to the level of the eighth month. 



THE DIAGNOSIS OF UTERINE PREGNANCY. 



Ill 



8. Changes in the Form of the Uterus. The lower uterine 
segment thins and distends ; the cervix becomes effaced from above 
downward. 

9. Changes in the Contour of the Abdomen. Until the 
end of the ninth lunar month the abdomen shows a regular curve. 
When the head sinks into the pelvis the epigastrium is flattened 
and the abdomen protrudes more prominently. 

10. Presentation of part or all of the fcetal parts is 
the last and most conclusive sign of pregnancy. 



Fig. 46. 



.9 




Showing the level of the fundus from the fourth to the tenth month. 



DIAGNOSIS OF THE LIFE OR DEATH OF THE FCETUS. 



Foetus is known to be living when the physician : 1 . Hears the 
foetal heart or foetal souffle. 

2. Feels the foetal movements. 

Foetus is believed to be dead when : 1. Foetal movements cease 
after having been felt by the physician. 

2. Foetal heart tones cease after having been heard by the physi- 
cian. 



112 SPECIAL DIAGNOSIS. 

3. Temperature of the vagina is lowered. 

4. Foetus loses its normal elasticity. 

5. Colored liquor amnii is discharged. 

6. Head of the child is softened. 

7. Mother loses flesh, breasts diminish in size, and there is 
general malaise. It is to be remembered that a dead fcetus may 
lie in the uterus weeks and months after full term. 



DIAGNOSIS OF THE TIME OF PREGNANCY AND PREDICTION 
OF THE DATE OF CONFINEMENT. 

The exact time of conception is rarely known, hence it is impos- 
sible to fix the exact date of confinement. The duration of normal 
pregnancy varies within wide limits. Pregnancy may be acci- 
dentally terminated by a fall, diarrhoea, shock, etc. The normal 
limits are placed at two hundred and forty to three hundred and 
twenty days. 

The data for determining the date of confinement are : 

1. From the date of a single coition count forward two hundred 
and seventy-two to two hundred and seventy-five days. 

2. From the first day of the last menstrual period count back- 
ward three months and add seven days. 

3. From the time of " quickening " count forward twenty-three 
weeks in multipara? and twenty-four weeks in primiparse. 

4. From the level of the fundus. (See Fig. 46.) 

5. From the size of the foetus — an uncertain method requiring 
long experience. 

Diagnosis of Multiparity. It may not be possible to say with 
certainty that a woman has given birth to a child. The following 
are the anatomical evidences of previous childbearing : 

1. Rupture of the Hymen and Perineum. The hymen may be 
congenitally absent; it may not rupture in labor, and is usually 
ruptured in coitus, masturbation, and in operations upon the lower 
genital tract. 

2. Laceration of the Cervix. The cervix may not be lacerated in 
labor, but may be by dilating for intra-uterine explorations and 
operations. 

Lacerations of the perineum, when direct violence can be excluded, 
are regarded as positive evidences of multiparity. 



THE DIAGNOSIS OF UTERINE PREGNANCY. 113 

3. Lacerations of the Vagina. When direct violence and opera- 
tions upon the vagina can be excluded, scars in the vaginal mucosa 
are regarded as evidences of multiparity. The smoothing out of 
the rugosities may be due to masturbation and coition, and cannot 
be regarded as conclusive evidence of multiparity. 

4. Mammary glands are pigmented, flabby, and show the striae 
gravidarum in a multipara, but these evidences are not always 
present, and, on the other hand, they may be present to a greater 
or less degree in women who have not borne children. 

5. Striae gravidarum are commonly found on the abdominal wall 
and thighs. They are the result of stretching of the skin from a 
growing tumor, and hence may result from abdominal distention 
from whatever cause, not only in multipara, but as well in prim- 
ipara, and in the male as well as in the female. While suggestive 
of pregnancy, they cannot be regarded as positive evidence. 

DIAGNOSIS OF MULTIPLE PREGNANCY. 

1. Unusually large uterus may be due to hydramnios, hydatid 
mole, large foetus, and uterine tumors complicating pregnancy. 

2. Groove in the fundus separating the foetuses. This is an 
unusual finding. 

3. Palpation of two heads or of two breeches — a positive evidence 
when elicited. 

4. Foetal heart tones heard in two separate areas and not syn- 
chronous. 

5. Vaginal touch demonstrating two separate and distinct pre- 
senting bodies — i. e., two heads, two breeches, or a head and a 
breech, or two separate and distinct protruding bags of membranes. 

6. Mensuration of the foetus, showing an abnormally long meas- 
urement for a single foetus. 

DIAGNOSIS OF THE CAUSES OF HEMORRHAGE OCCURRING 
DURING PREGNANCY. 

Any of the causes of hemorrhage from the non-gravid uterus 
(see page 28) may operate during pregnancy. We must, therefore, 
carefully distinguish between hemorrhage due to pregnancy alone 
and one resulting from some complication of gestation. In so 
doing we must exclude the possible existence of inflammatory 



114 SPECIAL DIAGNOSIS. 

lesions, of benign and malignant new formations, of ulcers and 
erosions of the cervix. 

It is often only with the greatest difficulty that we are able to 
determine the source of hemorrhage from the pregnant uterus. 
According to Winter, endometritis is the most frequent source. 
With the foetus in utero it is manifestly impossible to say with 
absolute certainty that endometritis exists. This fact is due to the 
unreliable symptoms, to the absence of any reliable physical signs, 
and, finally, to the impossibility of demonstrating by microscopic 
examination of scrapings the characteristic histological changes in 
the decidua before the termination of pregnancy. We are, there- 
fore, compelled to rely upon the history of endometritis previous to 
pregnancy and upon the exclusion of other possible causes. A 
negative history does not exclude the possibility of endometritis, 
because the various inflammatory lesions of endometritis may exist 
without symptoms and without apparent cause. 

The long continuance of the hemorrhage, the admixture of mucus 
with blood, and the habit of habitual abortion are suggestive of 
endometritis, but a positive diagnosis is only made by a micro- 
scopic examination of the decidua after expulsion of the egg. 

Placenta prsevia as a cause of hemorrhage occurring during 
pregnancy is a most important factor from a clinical point of view. 
Hemorrhage from placenta prsevia rarely occurs in the early months 
of pregnancy, and the liability increases up to the time of labor. 
The first loss of blood generally occurs after the eighth month. 

A characteristic feature of hemorrhage from placenta prsevia is 
said to be its occurrence in the intervals between uterine contrac- 
tions. The loss of blood may be instantly fatal or may slowly 
exhaust the patient's strength. The diagnosis rests upon establish- 
ing the fact of pregnancy and upon the physical evidences of a 
misplaced placenta. Under favorable conditions the edge of the 
placenta may be palpated through the abdominal wall. In a con- 
joined examination the foetal parts are indistinctly felt through the 
vagina, and ballottement may be impossible of demonstration. It 
is only possible to recognize placenta prsevia by feeling the placenta 
through the dilated cervix. The characteristic stringy feel of the 
placenta is noted. An incomplete placenta prsevia is recognized by 
sweeping the finger between the margin of the placenta and the sides 
of the cervix. In complete placenta prsevia this would be impos- 
sible. 



THE DIAGNOSIS OF UTERINE PREGNANCY. 115 

Hemorrhage from premature separation of a normally situated 
placenta (accidental hemorrhage) may occur late in the period of 
pregnancy or in labor. The hemorrhage is apparent or concealed. 
In concealed hemorrhage it is possible for death to occur without 
the blood finding its way out through the cervix. 

In making a diagnosis of the cause of the hemorrhage, placenta 
prsevia and rupture of the uterus must be excluded. The former 
can only be excluded by palpating or failing to palpate the placenta 
through the dilated cervix ; the latter is excluded from the fact that 
it occurs late in labor, the uterus diminishes in size, and a new 
abdominal tumor arises. 

In concealed hemorrhage there is, in addition to the usual 
general signs of internal hemorrhage, a sudden increase in the size 
of the uterus ; cessation or obscurity of the foetal movements and 
heart tones, and, finally, in place of the soft, elasticity of the normal 
pregnant uterus, there is a boggy consistency. 

THE DIAGNOSIS OF ABORTION. 

We may speak of abortion in progress, of incomplete abortion, 
and of complete abortion. In making a diagnosis of abortion we 
must first establish the fact of pregnancy. This is not always 
possible in early abortion without the presentation of part or all of 
the foetal structures. 

When hemorrhage from the uterus is associated with painful 
uterine contractions the diagnosis of pregnancy is most probably 
correct. An irregular hemorrhage, following upon a period of 
amenorrhoea in a woman sexually mature, is always suggestive of 
pregnancy, and when the uterus corresponds to that of pregnancy 
the diagnosis of incomplete or threatened abortion is made with 
certainty. Through the dilated cervix it may be possible to see or 
feel the presenting part of the ovum. 

The diagnosis of an abortion is manifestly more difficult when it 
is not certain that pregnancy has existed. This difficulty arises 
in abortions of the second month when the expected menses are 
delayed and there follows a hemorrhage unlike the menstrual flow 
in appearance and in amount. That pregnancy exists is suggested 
by the period of amenorrhoea, the softening and discoloration of the 
cervix, the slight enlargement and softening of the uterus, and the 
discoloration of the vagina and vulva. These evidences of preg- 



116 SPECIAL DIAGNOSIS. 

nancy, together with the unexpected appearance of a uterine 
hemorrhage, are all but conclusive proofs of an abortion. All blood 
expelled should be carefully searched for foetal tissue. 

After establishing the fact of pregnancy and of abortion, it then 
becomes imperative to determine whether the abortion is complete 
or incomplete. With but few exceptions the hemorrhage will con- 
tinue as long as the uterus is not thoroughly emptied, and will cease 
the moment all the foetal structures are expelled. 

It is to be remembered that in some women there is a periodical 
flow of blood for one, two, or more months after conception. We 
may say with certainty that abortion is complete when the expelled 
ovum is intact, or after a digital or instrumental exploration of the 
uterine cavity. We may say with certainty that abortion is incom- 
plete when only a portion of the ovum is known to have been 
expelled or when foetal remains are found in the uterus by explor- 
ing with the finger or instruments. 

THE ANATOMICAL DIAGNOSIS OF PREGNANCY. 

The diagnosis of pregnancy may not be made with certainty from 
the subjective and objective signs. There may be a complete absence 
of all subjective symptoms, or the patient may deny their existence. 
Again, an early abortion may not be recognized by the patient as 
such, and the diagnosis must rest upon the macroscopic and micro- 
scopic examination of expelled masses and membranes or of scrap- 
ings removed by the finger or curette. 

The macroscopic diagnosis of pregnancy is made from naked 
eye inspection of particles removed from the uterus — i. e., chorionic 
villi, decidua, foetal body. It is not always possible to recognize 
these structures with certainty by the unaided eye, and in such 
cases the microscope is indispensable. 

The microscopic diagnosis of pregnancy is largely based upon 
the finding of chorionic villi. These are composed of a connective 
tissue framework in which are found foetal bloodvessels. The 
connective tissue is composed of round, spindle-shaped or stellate- 
shaped cells, with an intercellular mucinous substance identical to 
that of Wharton's jelly in the umbilical cord. Fibrillar processes 
join the cells forming a network. The bloodvessels coursing 
through the stroma are endothelial-lined canals in the early weeks 
of pregnancy ; later they acquire a muscular wall. As pregnancy 



THE DIAGNOSIS OF UTERINE PREGNANCY. 



117 



advances the embryonic connective tissue cells become matured 
into fibres forming a more compact stroma. The epithelial cover- 
ings of the villi in early pregnancy are composed of two distinct 
cellular layers. The innermost layer is that of Langhans, forming 
a single or double row of spindle-shaped cells immediately covering 
the stroma. In the early months of pregnancy Langhans' layer is 
clearly defined, but in the later months it may wholly lose its 
identity. 



Fig. 47. 



%l 



r. *&. 



f--' § '§ 
Sf % f 












4&K 



«I°e. 



' C-® ^-.-O^ 



'§1 



Sf 



^^ 



•4 






w 



f] 






x^% 



v- o* 






4H 



clV^H^fC 



'■^ 






Scrapings from a puerperal uterus. Chorionic villi and decidua are seen. There are no 
degenerative changes. 



Overlaying Langhans' layer is the syncytium, an irregular band 
of protoplasm containing many nuclei and vacuoles. The nuclei 
are round or oval, and take a deep stain. The protoplasm is finely 
granular, and contains vacuoles of considerable dimensions. Giant- 
cells and buds spring from the syncytium particularly at the top of 
the villus ; these also contain nuclei and vacuoles. 

The presence of chorionic villi in discharged membranes is proof 
positive of a uterine pregnancy. 

The decidua may be regarded as the endometrium of pregnancy. 



118 



SPECIAL DIAGNOSIS. 



It is, therefore, a maternal structure. The endometrium becomes 
thickened even to tenfold. This thickening is due to an increase 
in size of the various elements of the endometrium. From the 
beginning of pregnancy the connective tissue cells of the mucosa 
increase in size four and even six times their original proportions. 
This growth is due more to an increase in the cell protoplasm than 
to the cell nuclei. These hypertrophied connective tissue cells are 

Fig. 48. 





.\~'K\ 






..... . . 

. j 


r: J§| 


<v l \i 


-■^ 


ifl 


# x | 


- - 


'••> 


■ • 3 


...-jg"^ 


I 

1 




Y 

J" • 1 









Decidua of early pregnancy. The glands are large, irregular, and lined by a single layer of 
columnar epithelium. The interglandular connective tissue is relatively scant. 



known as decidual cells. In form they closely resemble squamous 
epithelium. The connective tissue spaces are almost wholly oblit- 
erated by compression. 

Veins and arteries which in the mucosa of a non- gravid uterus are 
scarcely visible in the decidua are large blood channels and spaces. 

It is most important to consider the changes in the glands. 
They become greatly enlarged and tortuous. Near their outlet the 
surrounding decidual cells compress the gland, and deeper in the 



THE DIAGNOSIS OF UTERINE PREGNANCY. 119 

decidua the glands are tortuous and enormously increased in size. 
These glandular changes divide the decidua into a compact and 
spongy layer. Above is the compact layer, where the glands are 
compressed and the decidual cells are closely packed together ; 
below is the spongy layer, where the decidua is honeycombed by 
distended, tortuous glands. In the expulsion of the placenta the 
line of cleavage is within the compact layer. The regeneration of 
the glands and surface epithelium originates in the gland epithelium 
of the spongy layer. 

The epithelium of the glands is transformed from the cylindrical 
type to the cubical or flattened, containing but little cell protoplasm 
and closely resembling squamous epithelium. Many layers of 
squamous epithelium have been observed. It is evident that a 
diagnosis of glandular endometritis or of malignant adenoma might 
be made where pregnancy is unsuspected. 



CHAPTER XVI. 

THE MICROSCOPIC DIAGNOSIS OF EXPELLED MEMBRANES 
FROM THE UTERUS. 

The physician will be called upon to determine the nature of a 
membrane or mass spontaneously expelled from the uterus. Here 
the microscope is indispensable. It. is of prime importance to first 
determine whether or not the membrane is organized. Placing the 
membrane in cold water, if it becomes friable and disintegrates it 
is unorganized. Under the microscope a fibrinous structure is seen, 
in the meshes of which are blood cells in all stages of disintegration. 

Fig. 49. 




Cast from uterine cavity in exfoliative endometritis, membranous dysmenorrhea, natural 

size. (After Costa.) 

Calcareous concretions may be expelled spontaneously or removed 
by the curette. They most probably come from calcareous deposits 
in mucous polyps or submucous fibroids. 

Of the organized structures, we will consider the decidua of intra- 
uterine pregnancy, the decidua of extra-uterine pregnancy, and the 
decidua of menstruation. The following table will give an exact 
presentation of the practical points in the differential diagnosis of 
these structures : 



PLATE XVI. 



**•*?& 



#&& 



" A "\ \J»* -"' '■'■'■■■ 






.*««* 










#' 



1 



^'■'-•■ L "_- •- •■r'-l-"-"-." " ~-"S: * 



K ^ ' -" ^e>-tt^ 



A',v. 



•W/w^HR&fc- " 



Placental Shadows; 



The section represents placental tissue scraped from 
the uterus ten weeks after an abortion. The degenerated 
villi are shown as "shadows." Islets of old blood are 
seen between the villi. 



MICROSCOPIC DIAGNOSIS OF EXPELLED MEMBRANES. 121 



The Diagnosis of Expelled Membranes. 



Decidua of intra-uterine Decidua of extra-uterine De cidua of menstruation, 
pregnancy. pregnancy. 



Clinical 
features. 



Macro- 
scopic 
findings. 



Micro- 
scopic 
findings. 



Symptoms and signs of 
pregnancy ; hemorrhage 
and pain accompanying 
the discharged mem- 
brane ; no extra-uterine 
pelvic tumor. 



Thick shreds with shaggy 
surface, or smooth, glist- 
ening membrane. 



Symptoms and signs of No evidence of pregnancy, 
pregnancy; often irreg- No extra-uterine pelvic 
ular ; hemorrhage and tumor, 
pain accompanying 
the discharged mem- 
brane ; extra-uterine 
pelvic tumor. 



Rough fibrous mem- 
brane ; no villous 
structures ; irregulari- 
ties on inner surface. 



Unorganized. Organized. 



Triangular 

cast of uterus, 

or bits of 

membrane ; 

surface 
smooth with 

sieve-like 
depressions. 



Fibrinous 
structure, 
external sur- 
face smooth, 
internal sur- 
face rough. 



Surface Seldom present Flattened ; may be want- Absent, 
epithelium. j ing. 



Glands. 



Stroma. 



Vessels. 



Fcetal 
tissue. 



Compressed 
above, widely 
dilated and* 
very irregular 
below ; epithe- 
lium flattened. 

Typical 
decidual cells. 



Very widely 
dilated ; walls 

composed of 
endothelium ; 

no muscula- 
ture. 

Chorionic villi 
amnion. 



Changes similar to intra- 
uterine pregnancy, 
though less marked. 



Decidual cells not so 
large: more intercellu- 
lar substance. 



Less widened blood 
spaces. 



Absent. 



Absent. 



Fibrinous. 



Absent. 



Absent. 



Cylindrical, 

rarely 

flattened. 

Zig-zag in 
their course : 
epithelium 
cylindrical. 



Round-cell 
infiltration ; 
i protoplasm 
i of cells in- 
creased. 

As found in 
endometritis. 



Absent. 



Decidual cells are hypertrophied connective tissue cells. There are 
causes of hypertrophy of these cells other than pregnancy, and hence 
it is that decidual cells are not pathognomonic of pregnancy. The 
only positive evidence of pregnancy in discharged membranes is the 
presence of chorionic villi. 



CHAPTER XVII. 

THE DIAGNOSIS OF ECTOPIC PREGNANCY. 1 

Etiology. I. Predisposing Causes : 1. Mechanical interference 
with the passage of the ovum through the tube from — 
(a) Tumors in and about the tube. 

(6) Persistence of the foetal type— small lumen and convoluted 
course of the tube. 

(c) Peritoneal bands constricting the tube and drawing it out 

of position. 

(d) Congenital anomalies in development, namely, diverticula 

rudimentary fimbriae. 

(e) Malposition of the tube, either congenital or acquired. 
2. Loss of cilia and epithelium through inflammation. 

II. Essential Cause. While the above conditions are frequently 
present, it is a matter of common observation that tubal pregnancy 
may occur in an apparently normal tube. 

Webster affirms that in ectopic pregnancy there is a genetic 
reaction in the tube which is essential to the implantation and 
development of the ovum in the tube as truly as is a similar genetic 
reaction in the uterus essential to uterine gestation. This genetic 
reaction consists in the formation of decidual tissue. It is claimed 
by Webster that a decidua, however limited, is always to be found 
in the pregnant tube. Without a decidua the ovum would find no 
abiding place in the tube, even in the presence of the above-named 
predisposing causes. In the event of a decidual formation in the 
tube these predisposing causes will serve to obstruct the passage of 
the ovum, making possible the implantation of the ovum in the 
tube rather than in the uterus. This genetic reaction has never 
been discovered in the ovary or in the peritoneal cavity, and hence 
it is that primary ovarian or abdominal pregnancy has never been 
positively demonstrated. 

Ectopic pregnancy may occur at any time during the period of 
sexual maturity, but with greatest frequency between the ages of 

1 The author acknowledges his indebtedness to J. Clarence Webster, from whose monograph 
on " Ectopic Pregnancy " much of the material in this chapter has been taken. 



THE DIAGNOSIS OF ECTOPIC PREGNANCY. 



123 



thirty and forty. It is stated that a long period of sterility pre- 
disposes to ectopic pregnancy, probably because of the existence of 
one or more of the above-named predisposing causes. Tubal gesta- 
tion occurs five times as frequently in multipara as in primipara— a 
fact which may again be explained on the ground of the develop- 
ment of the above predisposing causes. We occasionally see 
reports of cases in which a second, third, and even fourth gestation 
has occurred in the same tube, or has occurred alternately in both 
tubes. 

Pregnancy seems as frequent in one tube as in the other. Mul- 
tiple ectopic pregnancy is possible— that is, an ovum in either tube, 
a twin pregnancy in a single tube, a normal uterine pregnancy 



Fig. 50. 




Ectopic gestation in blind accessory fimbriated extremity of the right tube. (Jewett.) 

together with a tubal pregnancy, and, finally, uterine pregnancy 
together with pregnancy in both tubes. Hanna finds sixty-nine 
cases of tubal pregnancy associated with uterine pregnancy. 

There is no evidence of a uterine pregnancy occurring during 
the course of a tubal pregnancy. In nearly three-fourths of the 
cases the ovum develops in the ampullary portion of the tube and 
with about equal frequency in the interstitial and fimbriated 
portions. 

Classification. I. Ampullar tubal pregnancy, in which the ges- 
tation begins in the ampullar end of the tube. Ampullar tubal 



124 



SPECIAL DIAGNOSIS. 



pregnancy may persist as such, or the gestation sac may rupture 
from the tube. 

1 . Persistent. In rare instances the gestation in the ampulla 
may go to full term. The gestation sac is pedunculated, movable, 
incarcerated, or fixed by adhesions. When confined to the pelvis 
the uterus and ovary are crowded to the opposite side ; when large 
and lying in the abdominal cavity the uterus may not be displaced. 
As a rule, the gestation sac lies at the side of or behind the uterus, 
rarely between the bladder and uterus. Adhesions may firmly 
bind the tube, uterus, and ovary together. 



Fig. 51. 




Left Fallopian tube, with ectopic gestation in diverticulum, a, a. Gestation sac commu- 
nicating with diverticulum. (Jewett.) 

2. Rupture may occur early. The most likely exit is between 
the layers of the broad ligament, though not infrequently it rup- 
tures into the free peritoneal cavity. 

(a) Subperitoneo-abdominal gestation, in which the ovum escapes 
through the lower segment of the tube between the layers of the 
broad ligament. Here the ovum may perish or go on to full 
development. Rupture usually takes place not later than the four- 
teenth week. The escape of the foetus and blood may be gradual 
or abrupt. So gradual may the process be that no general disturb- 
ance will be caused, and, on the other hand, the foetus and blood 
may be discharged in such a manner as to occasion profound shock. 



THE DIAGNOSIS OF ECTOPIC PREGNANCY. 



125 



As the gestation sac enlarges the layers of the broad ligament are 
separated, the pelvic viscera are pushed to one side, the peritoneum 
is stripped from the bladder, uterus, rectum, and pelvic wall. 
Later, as the gestation sac increases in size, it burrows beneath the 
parietal and visceral peritoneum, crowding the viscera forward and 
to the side. 

The placenta may remain attached to the tube or escape with the 
foetus between the layers of the broad ligament and become attached 
to any of the raw surfaces. The tube may be stretched out over 
the gestation sac as a mere ridge. Rupture into the peritoneal 
cavity may take place at any time after the escape of the ovum 



Fig. 52. 




Ampullar tubal pregnancy. Foetus surrounded by a blood coagulum. 



and blood between the layers of the broad ligament. The danger 
to life in such an event is imminent, and immediate surgical inter- 
ference is imperative. 

Gestation Comes to an End. 1. By the formation of a 
hcematoma. The accumulated blood destroys the life of the foetus. 
The lower the attachment of the placenta the greater the hemor- 
rhage, and hence the greater liability of destroying the life of the 
foetus. The blood undermines the peritoneum, sometimes encircling 
the uterus and rectum, and displacing the viscera. Coagulation of 
the blood is rapid, and eventually complete absorption of the clots 
or the organization of the clots into adhesions follows. 



126 SPECIAL DIAGNOSIS. 

2. By Suppuration. This event is usually late. It is unusual 
for an acute abscess to follow an hematoma of the pelvis. The 
more intimate the relation to the bowel the greater the liability to 
suppurate. If the abscess is not opened by surgical intervention it 
may become absorbed, but will almost surely find its way to a 
hollow viscus or externally through the vagina or abdominal wall. 
Parry reports a case in which rupture occurred thirty-two years 
after the formation of an abscess. Twelve cases are recorded in 
which the foetus was discharged through the bowel. 

(b) Tuboperitoneal gestation, in which the placenta remains in the 
tube and the foetus escapes into the peritoneal cavity. The proba- 
bility of such a condition was long held impossible. The first 
authentic case reported was that of Croom. Webster made sec- 
tional, dissectional, and microscopic studies of the case, and proved 
the existence of tuboperitoneal gestation beyond dispute. Webster 
holds that it is as yet unproven that a foetus can escape into the 
peritoneal cavity free of its investing membranes and then develop 
to full term ; he doubts the probability of such an occurrence. 
Furthermore, it is as yet unproven that the early complete ovum 
can escape into the peritoneal cavity and there go on to develop. 
As stated by Webster, it is inconceivable that a villous covered 
ovum can escape into the peritoneal cavity and there await the 
development of intervillous blood spaces. 

Gestation may terminate by rupture of the tube and escape of 
blood into the free peritoneal cavity. The amount of blood lost 
may be insignificant and occasion no constitutional effects ; while, 
again, the blood may instantly escape in such large amounts as to 
jeopardize the life of the mother and foetus unless surgical inter- 
vention is prompt. The consequences to the mother are, therefore, 
dependent upon the extent of the tear, the rapidity with which the 
blood is allowed to escape, and, finally, upon timely surgical inter- 
ference. The foetus may plug the opening and prevent the escape 
of much blood, or the blood may escape at intervals and eventually 
assume large proportions without seriously depressing the patient. 

Interrupted hemorrhage may also be due to contraction and 
retraction of the tube and bloodvessels. Though the quantity of 
blood lost in an interrupted hemorrhage may be equally as great as 
in the immediate escape of an equal amount of blood, the effect upon 
the mother is far less serious. The later in pregnancy the rupture 
occurs the more serious the consequences, because of the unusual size 



PLATE XVII. 




Secondary Abdominal Pregnancy at Eight Months, Primarily Tubal. The 
primary attachment of the placenta is plainly discernible at the original 
tubal site. After rupture the placenta grew and became attached to a large 
surface on the anterior abdominal -wall. The child was delivered through a 
retro-uterine vaginal incision. 



THE DIAGNOSIS OF ECTOPIC PREGNANCY. 127 

of the rent, the failure of the muscular wall to retract, the presence 
of large blood sinuses, and the failure on the part of the fcetus to 
be absorbed. 

Prior to the end of the second month, if rupture takes place, the 
hemorrhage will usually not be great, and the fcetus will almost 
certainly be absorbed. Rupture has been known as early as the 
second week. The time of greatest frequency for rupture to occur 
is from the sixth to the fourteenth week. The greatest number 
rupture in the second month. 

The escaped blood accumulates in the most dependent portion of 
the pelvic cavity. There it is rapidly coagulated, and is later 
absorbed, suppurates, or is organized. 




Primary intraperitoneal rupture ; fifth week. Tube completely ruptured, a. Ovum still 
slightly adherent to its original site. (Jewett.) 

Fritsch says there is no case of pelvic hsematocele in which 
ectopic pregnancy can be positively ruled out ; while, on the other 
hand, such authorities as Kober and Freund have reported cases. 
It is unusual for acute peritonitis to follow the development of a 
hematocele, though it is the rule for peritoneal adhesions to form 
about the mass of escaped blood. 

Gestation may be Destroyed. 1. By the Event of Tubal 
Abortion. By tubal abortion is meant the escape of the ovum 
through the fimbriated end of the tube into the peritoneal cavity. 
This implies that the tube must be patent at its fimbriated end. 
The contractions of the tube expel the ovum, forcing it in the 
direction of least resistance. The nearer the attachment of the 
ovum to the fimbriated end of the tube, the greater the liability to 
abortion. Hemorrhage is rarely considerable. All that has been 



128 



SPECIAL DIAGNOSIS. 



said of tubo-abdominal gestation in reference to the fate of the 
mother and ovum applies to tubal abortion, though with less force. 
The hemorrhage is rarely so great and the foetus is usually absorbed. 
Hence the mother may and, indeed, often does suffer but little. 

2. By the Formation of a Mole. The foetus dies and is preserved 
in its entirety, forming a fleshy mole. The death of the ovum is 



Fig. 54. 




Intraligamentary rupture of 



tubal pregnancy. Rupture at the isthmus, with escape 
of the foetus. 



caused by an escape of blood into the foetal membranes. At first 
the mass appears like a fresh, firm, blood clot. Later it organizes 
and becomes paler as the blood absorbs and organizes. 

3. By the Formation of an Abscess. Secondary infection of the 
ovum and escaped blood, as a rule, occurs through the bowel. In 
this manner a pyosalpinx may be formed, leaving no trace of 
pregnancy. 



PLATE XVIII. 



^m^-- 







X. \ 



w 



'v^f: 






Tubal Pregnancy. 

The wall of the tube is thickened. The villi are vascular and 
near the centre of the lumen. Entangled in the meshes of the villi is 
an irregular blood clot containing numerous synevtial eells-this 
represents the foetal remains. 



THE DIAGNOSIS OF ECTOPIC PREGNANCY. 129 

4. By the formation of an adipocere, a lithopedion or mummy, where 
the foetus is far advanced in its development. 

II. Interstitial tubal pregnancy, in which that portion of the tube 
lying within the uterine wall encloses the gestation sac. This is 
an unusual location. There may be tubo-uterine pregnancy, in 
which the ovum lies partly within the interstitial portion of the 
tube, partly within the uterine cavity. Again, the ovum may first 
develop within the interstitial portion of the tube, and later be 
expelled into the cavity of the uterus (" tubal abortion "). The 
gestation sac forms a part of the uterine tumor, and lies within the 
attachment of the round ligament — all other forms of tubal preg- 
nancy lie external to the round ligament. Interstitial pregnancy 
may go on to full term ; the foetus may die at any period of its 
development, or, finally, rupture of the tube may permit the ovum 
to escape into the uterine cavity, between the layers of the broad 
ligament, or directly into the peritoneal cavity. In any event, the 
resulting hemorrhage may be fatal. 

III. Infundibular tubal pregnancy, in which the ovum is found in 
the infundibulum. This is an unusual condition. The behavior 
is similar to that of ampullar pregnancy. The tube is likely to 
adhere to surrounding structures, and by adhering to the ovary a 
tubo-ovarian pregnancy becomes possible. 

RETROGRESSIVE CHANGES IN A DEAD FCETUS. 

1. Mummification is a process of desiccation, the water being 
extracted from the foetus. In addition a deposit of earthy salts is 
often superimposed. 

2. Calcification, in which the foetal membranes and placenta, 
rarely the superficial parts of the foetus, are permeated and incrusted 
with lime salts. There is rarely formed a dense incrustation. It 
is not uncommon for an adhesive peritonitis to be set up about the 
lithopedion. The petrified ovum may remain in the tube, in the 
peritoneal cavity, or between the layers of the broad ligament for 
years without creating serious disturbance. Well-formed children 
may be born while the parent still carries a lithopedion. Death 
may result from peritonitis. 

3. Adipocere formation, in which the ovum is converted into 
a soap-like mass. Calcareous deposits may be found in the adipo- 
cere. 

9 



130 SPECIAL DIAGNOSIS. 

4. Gangrene of the foetus may result, and if surgical interference 
is not instituted death from septic infection and peritonitis will 
follow. 

It is possible for a perfectly healthy and well-formed child to be 
delivered by surgical means, but, as a rule, the foetus is poorly 
developed and not viable. 

ANATOMICAL CHANGES IN THE TUBE. 

Mucous Membrane. In the tubal mucosa decidual changes are 
always to be found (Webster). This view is not universally 
accepted. Webster has never failed to demonstrate a decidua in 
the tube, but finds great variation in the location and extent of the 
development. The early specimens more clearly show this so-called 
genetic reaction than do the advanced cases. The decidua may be 
confined to a narrow ring about the tube. It is, therefore, not 
strange that conflicting statements are made concerning the presence 
of a decidua in the tube. It is often necessary to make sections 
from various portions of the tube. 

As in uterine pregnancy, so in the tube we find a decidua vera, 
reflexa, and serotina. The decidua vera is composed of a spongy 
and compact layer, as in uterine pregnancy. In the compacta the 
decidual cells are closely packed together, while in the spongy 



EXPLANATION OF FIGS. 55 TO 61.i 

Fig. 55. Side view. Pregnancy complicated by hematocele of both broad ligaments ; blood 
clot posterior and to either side of the uterus, crowding the cervix forward. 

Fig. 56. Retro-uterine hematocele extending into both broad ligaments, the mass on the 
one side rising much higher than on the other, so that accumulation of blood feels to the 
touch like two distinct masses closely set together and sharply rounded above and at the sides. 

Fig. 57. Front view. Hematocele of left broad ligament extending anterior to the uterus ; 
felt as a hard tumor in the left vaginal vault close to the uterus ; easily felt through the vagina 
and in the left inguinal region. 

Fig. 58. Retro-uterine hematocele lifting the peritoneum high out of the cul-de-sac of 
Douglas, and extending into both broad ligaments. Easily felt on vaginal and abdominal 
palpation. 

Fig. 59. Front view. Hematocele in both broad ligaments extending in front of the uterus ; 
tumor larger on the right side than on the left, and divided on the left into two segments. 
The mass on the left side communicates with that on the right, high up in front of the cervix. 
Uterus pushed back to the posterior wall of the pelvis. 

Fig. 60. Side view. Retro-uterine hematocele, not extending to the sides of the pelvis. 
Mass felt between the uterus and rectum, lifting the peritoneum out of the cul-de-sac ot 
Douglas, and crowding the uterus forward. 

Fig. 61. Front view. Hematocele of the left broad ligament, lying close to the uterus ; 
easily felt through by vaginal touch and by palpation over the left iliac region. Crowds the 
uterus forward and to the right. 

1 Suggested by Kuhn, in Veit, Handbuch der Gynakologie. 



THE DIAGNOSIS OF ECTOPIC PREGNANCY. 

Fig. 55. 



Fig. 58. 



131 




Fig. 57. 



Fig. 61. 





132 SPECIAL DIAGNOSIS. 

layer they are separated by gland-like spaces formed by mucous 
folds. In later months the distinction between the compact and 
spongy layers is lost. In the earlier stages the surface epithelium 
remains intact, but as time goes on the cilia are lost, the cells 
become flattened, and, finally, wholly disappear. As in the endo- 
metrium, the decidual cells are derived from the connective tissue 
of the mucosa. They are essentially greatly enlarged connective 
tissue cells, and show great variation in size and form. In far 
advanced cases these cells become elongated into a fibrous structure, 
losing their decidual character. 

The decidua serotina, that portion of the decidua known as the 
placental site, is relatively larger than is the serotina of the preg- 
nant uterus. 

The decidua reflexa may or may not be present. Some authorities 
disclaim its existence. As stated by Webster, the tube lumen may be 
so small that the ovum pressing upon the wall of the tube makes 
the formation of a decidua reflexa impossible. On the other hand, 
the tube lumen may be exceptionally large, in which case a com- 
plete reflexa may be formed. As the ovum develops the reflexa 
becomes thin and early disappears. 

Beyond the attachment of the ovum the tubal mucosa may not 
suffer change. Not infrequently decidual changes are recognized 
throughout the entire mucosa of the tube. As the ovum enlarges 
and fills the tube the surface epithelium is compressed and wholly 
disappears ; so, also, with the decidua. 

The muscular wall of the tube varies in thickness in different 
sections and in the various stages of pregnancy. In the early 
months the musculature thickens through hypertrophy. In the 
later months pressure and stretching of the musculature may cause 
all traces of muscle fibres to wholly disappear. 

The peritoneal covering of the tube is stretched by the growing 
ovum. Inflammatory adhesions may form about the tube. 

Regarding the foetal membranes, there is little that differs from 
the membranes of normal uterine gestation. 

The Clinical Diagnosis of Ectopic Pregnancy. The clinical 
diagnosis of ectopic pregnancy is made, first, by establishing 
the fact of pregnancy, and, second, by locating the gestation sac. 
The subjective signs are of value in establishing the fact of preg- 
nancy, but the location of the gestation sac can only be determined 
by a physical examination. ;* 



THE DIAGNOSIS OF ECTOPIC PREGNANCY. 133 

The subjective signs may not differ materially from those of 
uterine pregnancy of a similar age. In the early weeks of an ectopic 
gestation the patient is seldom aware of any unusual complica- 
tions, while in the later months the symptoms seldom conform to 
those of normal pregnancy, and will give rise to feelings of appre- 
hension on the part of the patient. Xot so with the physical 
signs ; these are to be differentiated from the normal from the 
earliest time. 

1. Cessation of menstruation occurs in about one-half of the cases. 
The hemorrhage when present comes from the endometrium. 

2. Morning sickness occurs at about the same time and to about 
the same extent as in uterine preguancy. 

3. Nervous phenomena, such as ringing in the ears and despon- 
dency, are likely to be exaggerated above that of normal uterine 
gestation. 

4. Periodic colicky pains are unlike anything that should occur 
in normal uterine pregnancy. It is this incident that commonly 
first attracts the patient's attention to her condition. These pains 
are said to be due to the contractions of the uterus and pregnant 
tube. In character they are intermittent and cramping, and are 
located in the region of the uterus and affected tube. During these 
pains rupture of the gestation sac may occur. 

The objective signs differ essentially from those of uterine gesta- 
tion. 

1. The mamma/'}/ glands do not often show the marked changes 
accompanying uterine pregnancy. The areola is poorly marked 
and the secretion of cholostrum is scant. 

2. Discoloration of the vulva and vagina, softening of the vaginal 
portion of the cervix and compressibility of the lower uterine segment 
may all be present, but seldom to the degree found in uterine ges- 
tation. 

3. Active fcetal movements may be recognized earlier and with 
greater ease than in uterine pregnancy, provided the foetus lies in 
close proximity to the abdominal wall. Later on the movements 
may be readily seen through the parietes. 

4. Intermittent uterine contractions are often present, though not 
to the degree found in uterine pregnancy. 

5. Direct palpation of the foetal parts may be very difficult and 
obscure, or very easy, depending upon the relation of the foetus to 
the abdominal wall. 



134 SPECIAL DIAGNOSIS. 

6. Auscultation, a. Foetal heart tones are heard, with varying 
degrees of distinctness, depending upon the development of the 
foetus, its relation to the abdominal wall, and upon the thickness of 
the latter. 

b. The foetal souffle is rarely heard, and only in the latter half of 
pregnancy. 

c. The placental souffle is rarely heard after the third month, 
and only on the side occupied by the gestation sac. 

7. The rate of growth, form, position, and consistency of the uterus 
varies considerably from that of uterine gestation. While the 
uterus almost always enlarges, it never attains a greater size than 
that of a four months' pregnant uterus, and does not enlarge regu- 
larly and progressively as does the gravid uterus. The nearer the 
gestation sac is to the uterus the larger the uterus develops. Cases 
are recorded in which the uterus did not develop, but these are 
exceedingly rare. 

The general contour of the uterus differs somewhat from that of 
the normal pregnant uterus. It retains much the same form as does 
the non-pregnant uterus. The transverse diameter is proportionately 
less, and there is no shortening of the cervix in advanced cases. 

The uterus seldom lies in the median line, but is crowded to one 
side by the gravid tube. 

In consistency the uterus changes, but not to the degree found 
in uterine gestation. 

8. The discharge of the uterine decidua is an event peculiar to 
ectopic pregnancy. Part or all of the uterine decidua may be 
expelled at any time during the course of an ectopic pregnancy. 
As a rule, the decidua is expelled piecemeal, rarely in its entirety. 
Much blood may accompany the discharged decidua and completely 
mask the accompanying fragments. Where ectopic pregnancy is 
suspected the escaped blood should be carefully preserved by the 
nurse for the inspection of the physician. 

Histologically, the uterine decidua of ectopic pregnancy does not 
differ essentially from that of uterine gestation, the distinguishing 
feature being the absence of foetal structures. 

Spurious Labor. At full term pains not unlike those of labor 
come on and constitute what is known as spurious labor. These 
pains may occur weeks before the end of full term, and, on the 
other hand, may altogether fail or be delayed one or more months 
beyond full term. The pains commonly continue a number of 



THE DIAGNOSIS OF ECTOPIC PREGNANCY. 135 

hours, as in normal labor, bat have been known to persist for a 
week and longer. They vary in intensity and location ; often they 
are severe and located in the side of the pelvis. A bloody dis- 
charge appears shortly after the onset of the pain, and with it there 
is usually a discharge of decidual membrane. The amount of blood 
lost may be alarming. 

Following spurious labor the foetus always dies, the liquor amnii 
becomes absorbed, the gestation sac contracts, and the foetus under- 
goes changes previously referred to, namely, mummification, litho- 
pedion, gangrene, and adipocere formations. 

9. " Intraperitoneal Hemorrhage. It may be stated at the outset 
that its signs and symptoms consist, speaking generally, of the signs 
and symptoms of an acnte and sudden abdominal lesion plus those 
of severe internal or concealed hemorrhage, and that whenever 
these are present in a female patient during the childbeariug age, 
the probability of their being due to a disturbed ectopic gestation 
should be vividly present to the physician's mind. The first symp- 
tom is the occurrence of a sudden and severe pain in the abdomen, 
accompanied very often with vomiting. The patient almost imme- 
diately expresses herself as feeling extremely faint and ill. She is 
quite conscious, and remains so. The abdomen is often more or 
less distended and rigid, and it becomes excessively tender. There 
is soon noticed, along with the usual signs of collapse, a gradually 
increasing pallor of the surface. The pulse increases in frequency, 
without, at first, any corresponding rise in temperature, and becomes 
weaker and more compressible. Presently it is only now and then 
that it is perceptible, and finally it cannot be felt at all. The 
patient complains of feeling more and more faint ; her pain perhaps 
abates ; she becomes restless, sometimes vomits, often sighs deeply, 
yawns and exhibits other signs of weariness, and, if left untreated, 
gradually sinks, maintaining a perfectly clear intellect to the 
last. 

"Such is a picture, imperfect, as all attempts to describe such a 
condition in words must be, of the clinical aspect of a patient with 
diffuse intra-abdominal hemorrhage. Now and then the bleeding 
becomes spontaneously arrested, the patient rallies, and, if no fresh 
outburst occurs, the blood becomes gradually absorbed and the 
patient recovers. But the condition is one in which no such for- 
tunate result can be counted upon, and in which the tendency is 
not to recovery, but to death, and to very speedy death, for the 



136 SPECIAL DIAGNOSIS. 

majority of cases end fatally within forty-eight hours, and many 
within a much shorter time. In the case of the wife of a medical 
friend of my own, death occurred within three hours from the 
beginning of the attack. 

" If I were asked upon what points I should principally rely in 
diagnosing this condition, I should be disposed, in the light of my 
own experience, to enumerate the following, viz. : 

" {a) The fact that at the moment of the attack the patient was 
in her usual health. This circumstance would render it highly 
improbable that the symptoms were due to gastric or intestinal per- 
foration or to rupture of an internal abscess or suppurating cyst. 

" {b) The gradually increasing pallor of the patient and the 
gradually rising pulse rate (without corresponding rise of tempera- 
ture), both being indicative of internal hemorrhage. 

" (c) The extreme tenderness of the abdomen. To this symptom 
I have learned to attach a very special value. It often misleads 
the medical attendant into supposing that there is acute general 
peritonitis. It cannot, therefore, be too strongly insisted upon that 
marked, and even excessive, abdominal tenderness does not neces- 
sarily indicate an inflammatory condition. It is met with, for 
instance, over ovarian tumors when, as the result of rotation of the 
pedicle, they have become the seat of hemorrhages, intracystic and 
intramural. It is quite true that peritonitis is a not infrequent later 
result of this accident, but this marked tenderness may be observed 
when, on opening the abdomen, there is no visible sign of inflam- 
mation. 

" (d) If a menstrual period has been missed or is overdue, the 
diagnosis of the case is greatly facilitated ; but it does not follow 
that because menstruation has been regular rupture of an ectopic 
gestation may be excluded. For some of the most appallingly 
sudden cases of rupture occur (as I hope to point out later) at a 
very early stage of the pregnancy, even, it may be, before a single 
period has been missed. Hence arrested menstruation is not essen- 
tial to the diagnosis, though when present it is a valuable help to it. 
If in addition to the arrested or delayed menstruation there is 
morning sickness, the diagnosis is even further facilitated. But, 
after all, these signs of early pregnancy do not prove very much. 
They do not even prove that the pregnancy, if present, is ectopic, 
or that, whether it is or not, it has anything to do with causing the 
present illness. All that can be said is that Avhen symptoms are 



THE DIAGNOSIS OF ECTOPIC PREGNANCY. 137 

present that suggest the possibility of a raptured ectopic gestation 
these signs of pregnancy serve to confirm the suspicion. 

" These are, so far as I have been able to observe, the main helps 
to a correct diagnosis. 

" There still remains to be considered one or two other points of 
diagnosis of less importance than those just indicated. 

" It is frequently stated in text-books that when there is intra- 
abdominal hemorrhage there will be the usual signs of the presence 
of free fluid in the peritoneal cavity. In a case of very extensive 
effusion, and in a patient without much fat in the abdominal wall, 
it may be possible to obtain evidence of fluctuation and of dulness 
in the flanks, shifting on change of posture, but such evidence is not 
usually forthcoming. 

"Lastly, a word must be said as to the evidence obtainable by 
vaginal examination. Here, again, the signs are not very definite. 
There is no distinct circumscribed swelling to be felt, as in the case 
of encysted effusions (pelvic hematocele). All that can be made 
out is, in the words of my friend Mr. John W. Taylor, ' a full and 
boggy condition of the pouch of Douglas, suggestive/ to the expe- 
rienced finger, l of the presence of fluid or semiclotted blood within 
the pelvis, but,' as he goes on to say, ' the symptoms denoting that 
a lethal hemorrhage is actually taking place are of chief importance.' 

" There is very often a slight hemorrhage going on from the 
vagina, generally regarded by the patient either as due to the ap- 
pearance of a delayed menstrual period, or, if she believes herself 
to be pregnant, as indicating the probability of a miscarriage. 

" Owing to the gradual subsidence of the pain, and the patient's 
freedom, as a rule, from anything like alarm about herself, the 
extreme gravity of the condition may easily be overlooked. In 
fact, as Mr. Taylor has pointed out, it is more frequent to find that 
the medical attendant has failed to appreciate the danger than that 
he has made an incorrect diagnosis " (Culling worth). 

10. Bimanual Examination. An anesthetic will be found of 
immense advantage in making a bimanual examination. Great 
variations are observed in the local findings of ectopic pregnancy. 
Vessels are felt to pulsate in the vaginal vault, particularly on the 
side of the gestation sac. The vagina may be displaced and mis- 
shaped by the gestation sac and accumulated blood above. The 
vaginal walls are made to bulge at the sides and behind the uterus, 
and the vagina may be pushed far to one side. 



138 SPECIAL DIAGNOSIS. 

The uterus is almost invariably displaced by the tumor mass. 
The most common displacement is forward and upward, because of 
the frequency with which the blood collects in the pouch of Douglas. 
The uterus is elongated, but is never so broad as in uterine gestation 
of a similar period of development. Its consistency is firmer than 
in uterine pregnancy, the lower uterine segment is not well-marked, 
and the cervix is not shortened. 

The pregnant tube is not unlike the inflammatory swellings of 
the tube. Without other evidences of pregnancy it would be 
impossible to say, with assurance, that the tube is pregnant and not 
distended with blood, pus, or serum. As in sactosalpinx the preg- 
nant tube commonly lies low at the side of or behind the uterus. 

In interstitial pregnancy the gestation sac forms with the uterus 
a single mass, distinguished by a more elastic consistency as con- 
trasted with the firmer uterine tissue. 

Differential Diagnosis. 1. Pregnancy in a Retroverted Uterus. 
Since the gestation sac of an ectopic gestation frequently lies behind 
the uterus, and since in the early months the size, form, and con- 
sistency of the uterus of an ectopic pregnancy does not differ widely 
from that of intra-uterine pregnancy, confusion is likely to arise. 
Here an anaesthetic examination is of the greatest value. Under 
anaesthesia the uterus should be located and clearly outlined apart 
from any mass outside. In ectopic pregnancy lying in the retro- 
uterine space the uterus lies well forward, and by its form and con- 
sistency can usually be outlined apart from the gestation sac. The 
anatomical distinctions between the pregnant uterus and the uterus 
of an ectopic pregnancy are to be borne in mind. In uterine preg- 
nancy the uterus is more elastic and soft, the lower uterine segment 
is clearly defined, and the transverse diameter is relatively increased. 
The possibility of a combined uterine and extra-uterine gestation is 
to be borne in mind. 

2. Uterine pregnancy complicated with a tubal or ovarian swelling 
may easily be confused with ectopic pregnancy. The difficulties 
are increased when the uterus is enlarged through inflammation 
(chronic metritis). Such a uterus when gravid will not have the 
usual elasticity and softness of a normal pregnant uterus. On the 
other hand, the abdominal wall and uterine musculature may be so 
thin as to give the impression that the foetus lies outside the uterus. 
In the first trimester the physical examination of the uterus alone 
can only serve to suggest the possibility of pregnancy. When from 






THE DIAGNOSIS OF ECTOPIC PREGNANCY. 139 

the size, position, consistency, and contour of the uterus pregnancy 
is suspected, the next step is to determine whether the adnexse are 
enlarged from pregnancy, infection, or a new formation. The his- 
tory must be caref ally considered, with special reference on the one 
hand to pregnancy and on the other hand to infection. The preg- 
nant tnbe is usually of softer consistency and less tender to pressure 
than are inflammatory swellings. More confusing, still, is the 
occasional occurrence of a tubal pregnancy implanted upon an 
inflammatory swelling of the tube. Here, and, indeed, in all cases, 
the history will be of the greatest value in making the differential 
diagnosis. The unilateral involvement of the tube is evidence 
in favor of tubal pregnancy, though bilateral tubal pregnancy 
is possible and unilateral involvement of the tube and ovary is 
common. A pregnant tube is not so likely to be fixed by adhe- 
sions as is a salpingitic swelling, and tenderness on pressure is not 
so great. 

As a last resort, when a diagnosis is imperative, a sound may be 
passed into the uterus, or if there is evidence to support the belief 
that an abortion has occurred, the uterus may be curetted and a 
microscopic examination made of the scrapings. If decidua and 
fcetal tissue are found the pregnancy must have been intra- 
uterine. 

If no decidua is found we are not to conclude that tubal preg- 
nancy cannot possibly be present, because it is possible that the 
decidua was previously expelled. 

Pelvic Exudate, Especially when Following upon an Abortion. A 
period of amenorrhoea may be interrupted by uterine hemorrhage. 

INo foetal structures may have been recognized in the escaped 
blood. From such a history the examining physician is unable to 
decide whether it was a uterine abortion or a ruptured tubal preg- 
nancy. If not examined until some time has elapsed and there is 
found a mass in the pelvis the question will arise as to whether 
there exists an inflammatory exudate or the gestation sac and the 
escaped blood of a ruptured ectopic pregnancy. If an inflammatory 
exudate, the history should point to a pelvic infection following the 
abortion, to a rise of temperature, and pain in the pelvis. The 
mass should be firmly fixed and tender to pressure. In ectopic 
pregnancy there is less tenderness and pain, and the general symp- 
toms of sepsis are not present unless the mass has become infected. 
A very good general rule to be remembered is that in a pelvic 



140 SPECIAL DIAGNOSIS. 

abscess the fever and high pulse rate precede the development of 
the pelvic exudate, while in ectopic pregnancy there is no fever or 
rise of pulse rate before the development of the tumor. Further- 
more, with the development of the inflammatory exudate the general 
symptoms of infection increase, while with the sudden appearance 
of an escaped mass following upon the rupture of a gravid tube 
the temperature is likely to become subnormal. 

Finally, an exploratory puncture or incision through the vaginal 
wall will determine the true nature of the swelling. If a pelvic 
abscess develops it may not be possible to determine whether it was 
derived from an inflammatory exudate or from a secondary infec- 
tion of an ectopic pregnancy. In the removal of the pus, foetal 
tissue may or may not be discovered either by the naked eye or by 
the microscope. 

Pregnancy in a bicornate uterus may closely resemble an ectopic 
pregnancy. The diagnosis may be cleared up by the discovery of 
a septum in the vagina or cervix. It is seldom possible to palpate 
the round ligament, but if found to be attached to the uterus 
external to the gestation sac the pregnancy is either interstitial or 
in a horn ; if the round ligament lies internal to the gestation sac a 
tubal pregnancy is positively present. 

Pregnancy in a rudimentary horn cannot be distinguished from 
tubal pregnancy before opening the abdominal cavity. It is then 
recognized by finding the insertion of the round ligament external 
to the gestation sac. 

Ovarian tumors may be difficult to distinguish from an ectopic 
pregnancy. In ovarian tumors the breasts may enlarge and secrete 
cholostrum, and there may be morning sickness and amenorrhoea. 
With the aid of an anaesthetic a bimanual examination should deter- 
mine the diagnosis. As a rule, the uterus can be clearly outlined 
distinct from the ovarian tumor, and is found not to differ from the 
normal non-gravid uterus. 

Rupture of an ovarian cyst may suggest a possible rupture of an 
ectopic pregnancy. The absence of a history of pregnancy, the 
presence of a long-standing tumor, and the absence of changes in 
the uterus suggestive of pregnancy, including a decidua, should 
suffice for the making of a diagnosis. 

Torsion of the pedicle of an ovarian cyst may give rise to pain 
and symptoms of internal hemorrhage not unlike those of a ruptured 
ectopic pregnancy. A consideration of the points referred to in the 



PLATE XIX 



\?i^\ ^ . 




Retro-uterine hsematoma crowding the eul-de-sae of Douglas up, 
and the uterus upward and forward. 



THE DIAGNOSIS OF ECTOPIC PREGNANCY. 141 

above paragraph on rupture of an ovarian cyst should serve in 
excluding rupture of an ectopic pregnancy. 

An ovarian tumor complicating pregnancy is at times confusing in 
the diagnosis. The shape, size, and consistency of the uterus will 
usually serve in determining the presence of a uterine pregnancy. 
The great improbability of a tubal pregnancy complicating a uterine 
pregnancy, together with the usual signs of an ovarian cyst, will 
usually clear up the diagnosis. If the cyst is large it will be 
observed that there is an absence of ballottement, of foetal heart 
tones, of foetal movements, in what is suspected of being a gesta- 
tion sac. 

Fibromyoma of the uterus can scarcely be mistaken for ectopic 
pregnancy. There is an absence of a history of pregnancy. The 
uterus shows none of the changes characteristic of pregnancy. The 
tumor is of long standing, which, together with its firm consistency 
and close relation of the uterus to the tumor mass, should leave 
little doubt as to the diagnosis. An exploratory curettage of the 
uterus will fail to find a decidua. 

Malignant disease of the pelvis by its irregular outline may sug- 
gest an ectopic pregnancy, and the more so when occurring in the 
" dodging period." The absence of the signs of pregnancy and 
the presence of general signs of malignancy should exclude the 
possibility of ectopic pregnancy. 

Pelvic haematoma and haematocele not due to ectopic pregnancy are 
exceedingly rare. Causes other than ectopic pregnancy resulting 
in the formation of a haematoma or hematocele are obstructions to 
the outflow of the menstrual blood, rupture of varicose veins in 
the broad ligaments, rupture of an ovarian cyst and of the uterus. 
In determining the origin of the blood mass the first and most 
important step is the consideration of pregnancy. In long-standing 
cases of haamatoma and haematocele following upon the rupture of 
an ectopic pregnancy it may be impossible to find any evidences of 
pregnancy either in the tube or in the uterus. 



CHAPTEE XVIII. 

DIAGNOSIS OF HYDATIFORM MOLE. 

Synonyms. Hydatiform degeneration of the chorion ; uterine 
hydatids ; vesicular mole ; myxoma chorii ; blasenmole ; cystic 
mole; hydatid mole; dropsy of the Villi. 

History. In a valued contribution by E. Kossman, Berlin, we 
are given in the German text translations of the original manu- 
scripts on hydatiform mole from the time of ^Etius von Ameda, in 
the early part of the sixteenth century, to the time of Virchow, in 
the latter part of the nineteenth century. 

Hippocrates was evidently acquainted with the condition as a 
cause of abortion. . He states that when the " cotyledons " fill with 
mucus the menses become scanty ; and if the woman becomes 
pregnant, abortion occurs after the embryo has attained considerable 
size. 

It is interesting to note that as late as the early part of the nine- 
teenth century it was believed that conception was not essential to 
the development of a hydatiform mole. Dating from the writing 
of Velpeau, the lesion has been universally recognized as a degen- 
eration of the chorionic villi. Since then it has been a question as 
to the cause of the degeneration of the chorionic villi and the char- 
acter of the degeneration. Virchow may be credited with having 
advanced the modern theory as to the pathological nature of 
hydatiform mole, though his views are not universally accepted. 
(See later.) 

Etiology. Nothing definite is known of the immediate and 
remote causes of hydatiform mole. The age at which it commonly 
occurs is said to be near the end of the childbearing period. 
According to Bowin, 25 per cent, are found between the ages of 
forty and forty-six years. Schroeder reported one occurring at seven- 
teen years of age. In 210 cases tabulated by the author it is seen 
that the average age is twenty-seven years ; that the extreme ages 
are thirteen and fifty-eight years, and that the greatest number 
occurs between the ages of twenty and thirty years. As to the fre- 



DIAGNOSIS OF HYDATIFORM MOLE. 



143 



quency of recurrence, it is Dot unusual for a woman to give birth 
to a second mole some months or years after the expulsion of the 
first. In the second case here reported there was an interval of 
about twenty months between the expulsion of the first and second 
mole. Fritsch records a case in which there were four moles suc- 
cessively developed. Majer records eleven moles and a single child 
born of one woman. 

It is stated that syphilis, ansemia, heart and kidney lesions, and 
tuberculosis are general predisposing factors in the production of 



Fig. 62. 




Section 01 the uterus with the mole in situ. 

hydatiform mole, but proof of this is wanting. The question as to 
whether the lesion is of maternal or of foetal origin is not fully 
settled. In favor of the view of the maternal origin may be men- 
tioned the recurrence of the mole in the same individual and by 
different husbands ; the common occurrence late in life ; the partial 
vesicular degeneration of the chorion in the presence of a perfectly 
healthy foetus ; the common occurrence of cystic degeneration of the 
ovaries associated with hydatiform mole ; and, lastly, that endo- 
metritis and nephritis commonly precede the development of 
hydatiform mole. In favor of the foetal origin is the fact that in 



144 SPECIAL DIAGNOSIS. 

twin pregnancy one mole alone may be involved in the cystic 
degeneration of the chorionic villi. If, as has been stated, death of 
the foetus is a cause for vesicular degeneration of the chorion, how 
are we to account for the rarity of the lesion in cases of missed labor 
and abortion, where the foetus has remained dead for weeks and 
months in the uterus ? The fact that in partial vesicular degenera- 
tion of the villi the foetus may remain perfectly healthy forces us to 
the more probable conclusion that extensive vesicular degeneration 
of the chorion results in the death of the foetus. Contrary to the 
evidence advanced in support of the theory of maternal origin is 
the occurrence of many moles prior to the formation of the placenta, 
at the time when there is not an intimate anatomical relation of the 
mole to the uterine wall. Marchand holds that hydatiform mole 
occurring early in foetal life can be ascribed to a primary change 
in the ovum. He does not deny the possibility of other causes 
operating to produce partial degeneration of the chorion, and 
admits as highly probable that malnutrition has much to do with 
the development of the mole. 

Van der Hoeven examined ten hydatiform moles, of which nine 
were in the third, fourth, and fifth months of foetal development ; 
the tenth was in the first month. The last showed no vesicular 
degeneration of the reflexal placenta. Van der Hoeven reasoned 
that the ovum was healthy when it reached the uterus, and that it 
is possible that the disease was primary in the uterine wall, though 
not probable. In support of the theory of uterine origin he found 
degenerative changes in the endometrium. Virchow was the first 
to suggest the possible causal relation of endometritis to hydatiform 
mole. From the great frequency of endometritis complicating 
pregnancy as compared to the relative infrequency of hydatiform 
mole, it is not likely that any direct relationship between the two 
lesions can be established. It would be difficult to determine 
whether the changes in the endometrium are primary or secondary 
to the development of the mole. Again, the histological changes 
in the endometrium associated with hydatiform mole are by no 
means constant. It has been suggested by Baumgart, Marchand, 
Kaltenbach, Krentzmann, Runge, Fraenkel, and others that the 
tendency to cystic degeneration of the ovum may be referred to 
cystic degeneration of the ovaries. Each of the above-named 
authors has reported a case of hydatiform mole complicated by 
cysts of the ovary, and in a single case there was also a cystic 



DIAGNOSIS OF HYDATIFORM MOLE. 



145 



kidney. In my second case both ovaries were cystic, each about the 
size of a man's fist. In 210 recorded cases tabulated by the author 
in only 8 were cystic ovaries recorded. The number of abdominal 
incisions made in these cases is few — a fact which possibly accounts 
for the above statistics. On the other hand, cystic degeneration of 
the ovaries is so commonly observed as compared with hydatiform 
mole that it is not likely that they stand in the relation of cause 
and effect. 

Fig. 




Section of the uterine musculature, decidua, and mole. X 4. 

Matwejew and Sykow reported in the Gynecological Society of 
Moscow a case of tubal pregnancy in which the placenta had under- 
gone cystic degeneration, and the ovary was likewise cystic. The 
patient was aged thirty-two years ; she had had four normal labors 
and three abortions. The right tube contained the ovum, which 
ruptured about the eighth week of pregnancy. Symptoms of 
internal hemorrhage followed the rupture of the tube. Abdominal 
section revealed a large collection of blood in the pelvis, a ruptured 
tube, within which there was an hydatiform mole. The author 
stated that the cystic ovaries were undoubtedly the cause of the 
cystic degeneration of the placenta. 

10 



146 



SPECIAL DIAGNOSIS. 



Microscopic Examination. The Decidua Vera. The glands do 
not differ essentially from those of normal pregnancy. In size, 
number, and general outline there is nothing unusual. The secret- 
ing epithelium of the glands is partially lost ; the remaining cells 
are cubical or flattened. In the gland lumen are many desquamated 
and degenerated epithelial cells and not rarely free blood and 
leucocytes. The decidual cells present no anomalies in structure ; 
as in normal pregnancy they present a variety of forms, the greater 
number being polygonal or spindle-shaped. In the compacta they 
are more uniformly spindle-shaped, with elongated nuclei. Free 
blood together with groups of leucocytes are found between the 
decidual cells and the musculature. 

The Decidua Serotina. On the surface of the decidua serotina is 
a thin, fibrinous layer in which decidual cells are scattered. The 

Fig. 64. 




Cystic degeneration of a villus, with an islet of syncytium within the degenerated stroma. 

decidual cells are round, polygonal, and spindle form, with large, 
round, granular nuclei. The glands are large, irregular in form, 
and the secreting epithelium flattened or cubical. Bloodvessels 
are intimately associated with the decidual cells, and free blood is 
found in the decidua and musculature. 

Chorionic Villi. It is observed that the intensity of the stain is 
subject to great variation, particularly in the connective tissue 
stroma. The larger the villus the fainter is the stain ; while in the 
largest villi the central portion of the stroma utterly fails to take a 
stain, thereby showing complete degeneration and loss of tissue. 
At the periphery of the villus, where the stroma is seldom if ever 
wholly lost, there is a faint stain, showing but partial degeneration. 
This is best shown by the Van Gieson stain. Great variations in 



DIAGNOSIS OF HYDATIFORM MOLE. 147 

staining are also shown in the epithelial layer, the cells lying nearest 
the stroma taking the stain more faintly than those at the periphery. 
The non-degenerated connective tissue of the villus is of the 
embryonal type ; the cells are elongated, having spindle-shaped 
nuclei. There is not the degree of development into fibrillse as 
described by Webster in the chorion of the fourth month, but it 
resembles in point of development the villus of four to six weeks' 
development. The first evidence of degeneration in the connective 
tissue is shown in the indistinct outline of the cell body, which 
becomes a granular substance beset with stellate cells containing a 
granular nucleus, and from which radiate fine fibrillar processes. 
Finally the formed elements disappear, and there is left an irregular 

Fig. 65. 





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k 


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Beginning degeneration of the stroma, with unusual proliferation of the syncytium. 

space filled with clear serous fluid. At the periphery, in close 
touch with Langhans' layer, there always remains more or less con- 
nective tissue, arranged in concentric layers, which is more fibrillar 
than that of the centre of the stroma. In none of the villi is the 
stroma wholly degenerated. The degeneration of the stroma is in 
direct proportion to the size of the villi ; in the smaller villi there 
is little if any degeneration. The process seems to be a granular 
degeneration or necrosis, with subsequent absorption, leaving 
spaces which fill with serum. I have not been able to demon- 
strate mucoid degeneration, as was first affirmed by Virchow. Storch 
took issue with Virchow on this point, and, after him, the lesion 
is spoken of as "cystoid degeneration of Storch/ 7 Other author- 
ities, while agreeing with Storch, disagree as to the manner by 



148 SPECIAL DIAGNOSIS. 

which this " cystic degeneration " is brought about. Merkle and 
Giese call it a secondary oedema due to an inhibited formation of 
the placenta. Koster and Rumler believe it to be an oedema of 
the stroma resulting from interference with the circulation through 
the pedicle of the vesicle. 

Krentzmann also takes issue with Yirchow. He says : " Vesic- 
ular mole is the result of an irregular proliferation of the epithelial 
parts of the chorion, with hydropic swelling and consecutive necrosis, 
manifested especially in the larger vesicles. The superficial stratum 
of the stroma — that which is near the living epithelium — remains 
unchanged, but the inner parts become liquefied." 

In addition to the above-named authorities may be mentioned 
Marchand, Fraenkel, and Neumann, who believe in the cystic 
degeneration theory as opposed to the myxomatous degeneration 
theory of Virchow. They speak of the proliferation of the 
epithelial elements as being coincident with the liquefaction of the 
stroma. 

Bloodvessels in the villi are difficult to demonstrate. Webster 
in describing the chorion of the sixth week of development says : 
u Most of the villi have capillaries. These consist simply of a tube 
of small, flat, endothelial cells around which the connective tissue 
is somewhat condensed, though to a different extent in various 
places." No bloodvessels were seen in the large cystic villi ; and 
when seen in the small, less degenerated villi they appear thicker- 
walled than is described by Webster (vide supra). No calcareous 
deposits were seen in the villi. The most significant changes centre 
in the epithelial elements of the chorion. There is seen an active 
and very irregular proliferation of the epithelial cells, with a ten- 
dency to invade the uterine structures to a degree not seen in 
normal pregnancy. Before degenerative changes are noted in the 
stroma the epithelial layers proliferate to an unusual degree. This 
proliferation of epithelium is particularly marked at the tips of the 
villi. The larger the villi the greater the proliferation. This pro- 
liferation, while similar in character, is to a greater degree than is 
found in normal pregnancy of the same age, and may surpass that 
found at any time of pregnancy. 

In the syncytium and Langhans' layer of the small villi there is 
little change from the normal. As the villi enlarge through degen- 
erative changes in the stroma and proliferation of the epithelial 
elements there are seen in the periphery of the villi, particularly 



DIAGNOSIS OF HYDATIFORM MOLE. 149 

at the distal end, clumps and buds of protoplasmic bodies taking a 
deep stain and containing irregular groups of nuclei. Irregular 
vacuoles are seen in these protoplasmic bodies. The protoplasm is 
finely granular, and takes a fainter stain than do the nuclei. The 
buds and clumps of protoplasm take a deeper stain than do the 
remaining portions of the epithelium. Here and there in the larger 
villi irregular nests of syncytium are seen in the stroma of the 
villi. These, according to Van der Hoeven, are 'prima facie evi- 
dence of malignancy. A careful study of my specimens relative to 
this phase has led me to the conclusion that such is often, though 
not always, an accidental finding, due to tangential cutting of the 
villus, and not to an active invasion of the stroma by the epithelial 
elements. These changes in the syncytium and Langhans' layers 
are essentially hyperplasia and necrosis of the cell elements ; the 
protoplasm increases in amount and the nuclei in size and number. 
The vacuoles are in number and size directly proportionate to the 
amount of epithelium, and are doubtless due to degenerative changes 
from malnutrition. Coagulation necrosis of the syncytium is more 
or less in evidence throughout the specimen. With the death of 
the foetus there is loss of the foetal blood supply to the villi. This 
does not necessarily result in necrosis of the villi, provided the 
maternal blood supply is sufficient to supply the needed nourish- 
ment ; on the contrary, the villi may continue to grow. 

According to Marchand, the foetal blood is of minor importance 
in supplying nourishment to the villi. As evidence of this he has 
demonstrated necrosis of the stroma in the presence of a foetal blood 
supply and in the absence of a syncytial covering. His conclusion 
is that the syncytium exercises a governing influence over the 
maternal blood supply to the stroma of the villi ; when destroyed 
the stroma will undergo degenerative changes. Marchand asserts 
that a well-formed stroma is found only w T here the maternal circu- 
lation is adequate and the syncytium intact. 

It is found that in partial moles where the maternal circulation 
is less disturbed the necrosis of the stroma is correspondingly less. 
It would appear, then, that the remote cause of the necrosis of the 
chorion lies in the failure on the part of the maternal circulation 
leading to degeneration of the connective tissue, and to a serous 
exudate which finally replaces the stroma of the villi. Peters 
believes the syncytium to be a sort of endothelial layer lining the 
intervillous spaces and exercising some important part in the func- 



150 SPECIAL DIAGNOSIS. 

tion of interchange between maternal and foetal circulation. 
Furthermore, that it serves to protect maternal blood from direct 
contact with Langhans' layer, which probably has some coagulating 
or destructive influence on the maternal blood. 

With a disturbance of the maternal circulation the reciprocal 
relations between the maternal and foetal circulation are altered, 
and, as a result, there is added to necrosis of the stroma a serous 

Fig. 66. 








ft K 




Group of degenerated villi, showing proliferation of the syncytium. 

exudate, with the formation of cystic spaces filled with clear serum. 
The accumulated fluid in turn causes further necrosis of the stroma 
through compression ; complete degeneration of the connective tissue 
fibres is seldom if ever seen. There is always a limited amount of 
fibres compressed in a concentric manner immediately beneath the 
Langhans layer. In the larger villi there is also pressure necrosis 
of the epithelial covering, affecting both Langhans' layer and the 
syncytium. 






DIAGNOSIS OF HYDATIFORM MOLE. 151 

Malignant Degeneration. The greatest interest in hydatiform 
moles centres in the fact of their liability to undergo malignant 
degeneration. Solowij and Krzysz-Kowski have shown that about 
10 per cent, of hydatiform moles become malignant. On the other 
hand, it is generally recognized that fully 40 per cent, of the cases 
of syncytioma malignum arise from hydatiform mole. In collect- 
ing reported cases of hydatiform mole I have found a scarcity of 
case-reports of non-complicated hydatiform mole ; that cases are 
seldom reported unless they have undergone malignant degenera- 
tion. For this reason it is impossible to arrive at any exact estimate 
of the frequency of hydatiform moles and of their malignant degen- 
eration. Referring to the reported cases, which include all I am 
able to find in the literature, it appears that 16 per cent, of hydati- 
form moles become malignant. For the reason stated above it is 
probable that this percentage is far too high. 

From the very onset the difficulties involved in dealing with the 
many mooted questions concerning the malignancy of hydatiform 
mole appear insurmountable. The intimate blending of foetal and 
maternal structures, together with the secondary processes of degen- 
eration, are so complicated and are so subject to variations that it 
is difficult and at times impossible to distinguish the benign from 
the malignant. Indeed, Van der Hoeven goes so far as to state 
that all hydatiform moles are malignant ; that the proliferation of 
the epithelial elements of the chorion (syncytium, Langhans) 
assumes a malignant type in the invasion of the uterine musculature 
and connective tissue stroma of the villi. He further reasons that 
if this tendency on the part of the epithelial elements to proliferate 
is not marked, or if the mole is expelled or removed before the 
epithelium invades the uterine tissue beneath the line of cleavage 
(within the compact layer of the decidua), there can be no recur- 
rence. If left behind in the uterine tissue, the epithelial elements 
continue to proliferate and to be carried to distant parts of the body 
by way of the blood stream, there forming metastatic malignant 
epithelial growths. 

Neumann studied 8 cases of hydatiform mole ; 5 were not fol- 
lowed by malignant changes, 3 died of syncytioma malignum. In 
the 5 so-called benign moles the epithelium of the chorion pro- 
liferated to an unusual degree, but did not invade the connective 
tissue of the stroma, while in the 3 malignant moles the connective 
tissue stroma was invaded by syncytial giant cells. Neumann 



152 SPECIAL DIAGNOSIS. 

arrived at the conclusion that the earliest evidence of malignancy- 
lay in the invasion of the connective tissue stroma of the villi by 
the epithelial elements of the chorion. As suggested by Pierce, the 
" view of Neumann is not generally recognized, and with right, for 
cases of nephritis and lead poisoning have since been described 
where the same cells were found in the stroma of normal villi ; 
hence their presence can have no pathological significance in 
hydatiform mole." 

It is evident from the observations of Veit, Webster, Pick, and 
others that the invasion of the deep structures of the uterus, and 
even of structures beyond the uterus, by chorionic epithelium, is 
not evidence per se of malignancy ; that, on the contrary, syncytial 
masses are found in the uterine musculature, and are deported to 
distant parts of the body by veins in normal pregnancy ; that soon 
after the termination of pregnancy they disappear. The transition 
between benign and malignant chorio-epithelial elements is a gradual 
and imperceptible one, just as is true in the transition of all benign 
hyperplastic growths into the malignant types ; and to differentiate 
them is manifestly impossible. There undoubtedly exists an inter- 
mediate stage between the benign and malignant. Berry Hart 
examined an hydatiform mole in which the epithelial changes were 
identical with those described in the malignant type ; no recurrence 
followed the expulsion of the mole. Both the syncytium and 
Langhans ? cells participate in the proliferative changes, but to a 
varying degree. There is, likewise, great variation in the rate of 
growth in the epithelial elements, the explanation not only lying 
inherent within the cell elements, but also in the degree of resistance 
offered by the uterine tissue. 

Two of the cases described by Kworostansky were in the second 
month of pregnancy— one a benign hydatiform mole, the other a 
syncytioma malignum. It is of the greatest interest to compare 
these two cases from an anatomical point of view. In the benign 
mole there was unusual proliferation of the syncytium and Lang- 
hans ? layer, forming a loose connection with the decidua serotina ; 
in the veins of the serotina both syncytial and Langhans' cells were 
found in limited numbers. The decidua vera was invaded to a 
lesser degree ; no epithelial elements were found in the uterine 
musculature. In the placental site were evidences of endometritis, 
as demonstrated in scrapings removed six weeks after the expulsion 
of the mole. The case recovered without recurrence. The author 



DIAGNOSIS OF HYDATIFORM MOLE. 153 

states that the patient, aged twenty-four years, was anaemic, and 
that this impoverishment of the blood afforded insufficient nourish- 
ment to the villi, thereby exciting the chorio-epithelium to extend 
deeper into the uterine musculature in order to obtain greater 
nourishment. Sufficient nourishment not being provided by the 
stroma of the villi, narcosis follows. In the second case, which 
was malignant, there was also extreme anaemia. The epithelial 
elements behaved similarly to that of the first case, only to an 
exaggerated degree, apparently differing only in the degree of 
epithelial invasion of uterine structures. The syncytial cells 
invaded the intermuscular spaces and veins of the uterus as far as 

Fig. 67. 




Distal end of a chorionic villi, showing beginning degeneration of the stroma, 

the parametrium. Atrophy and necrosis of the decidual and mus- 
cular elements followed ; bloodvessels were changed to blood lacunae. 
In comparing my specimen of benign hydatiform mole with one 
having undergone malignant changes, it was advisable to select for 
comparison not only one of similar age, but also one that had been 
removed together with the uterus, as was mine. In this way we 
avoid certain retrogressive changes and the disturbance of anatom- 
ical relations which would otherwise mislead. Two such cases 
have been reported — one by Poten and Vassmer, the other by 
Neumann. In both these cases the essential variation from my 
own case appears to lie in the more marked proliferation of the 
syncytium and Langhans ? cells and in their extended invasion of 
the uterine veins and musculature. While it is not to be expected 
that a benign mole may be recognized from a malignant mole by 



154 SPECIAL DIAGNOSIS. 

the naked eye, yet it is worth while to observe that Pautz and 
others have found in malignant moles that the villi rarely attain 
large size, are firm, and have a long, slender pedicle, giving to the 
mole the appearance of soft-cooked rice. 

Ladinski, in a recent clinical review of deciduoma malignum, 
reported a case of hydatiform mole followed by malignant degenera- 
tion. He collected thirty-three similar cases, and concluded that 
malignant degeneration occurred most frequently in cases where 
mole pregnancy terminated in the fourth month. It does not 
appear that the length of time a mole remains in utero has any 
influence upon its disposition to become malignant. In twenty 
cases Ladinski finds the average time of appearance of syncytioma 
malignum is eight weeks after the mole has been expelled. 

Diagnosis. The rate of growth of the uterine tumor is the most 
constant and characteristic sign of hydatiform mole. With few 
exceptions, the size of the uterus is greater, even to double that of 
the normal pregnant uterus of a like period. At twelve weeks it 
has been found larger than the average pregnant uterus at full 
term. The growth is not usually symmetrical ; in a number of 
cases the uterus is found to be proportionately broad. Further- 
more, the rate of growth is not uniform. Near the time of expulsion 
the uterus frequently assumes a very rapid growth, soon to be fol- 
lowed by uterine pains and profuse hemorrhage. Within twenty- 
four hours the uterus may ascend two or three fingers' breadth. 

Hemorrhage is usually the first symptom to attract the attention 
of the patient. Preceding the hemorrhage is a period of amenor- 
rhoea extending over one, two, or three months — rarely longer. In 
a single case hemorrhage appeared in the third week of gestation, 
and again as late as the fifth month. The usual time of occurrence 
is in the second and third months. It is occasionally stated that 
the hemorrhage is more profuse at night. This was true in my 
first case, there being very little loss of blood during the day and 
profuse bleeding at night. As a rule, the hemorrhage is at first slight, 
gradually increasing in amount and frequency, finally becoming 
continuous and in such quantities as to cause more or less anaemia. 
Hemorrhage is always to be feared at the time of the expulsion of 
the mole; this is particularly true when the mole is far advanced 
and when firmly adherent to the uterus. It has been known to 
recur within a week in a case that did not prove to be malignant, 
but such an event is exceptional. Where malignant degeneration 






DIAGNOSIS OF HYDATIFORM MOLE. 155 

has followed the birth of a mole hemorrhage is known to have 
recurred nine days after the mole was expelled, and as late as four 
and one-half years. Consulting the statistics, it is seen that hemor- 
rhage, ushering in malignant changes, first appears in the first and 
second months, with about the same frequency as in the fifth and 
sixth months following the expulsion of the mole. We may for- 
mulate the dictum that hemorrhage recurring weeks and months after 
the expulsion of an hydatiform mole is suggestive of malignancy, and 
demands immediate and thorough investigation into the cause. 

Nausea and vomiting are present in a larger percentage of cases 
than is common to pregnancy. Severe and uncontrollable vomiting 
occurred eighteen times in the 210 collected cases. The explanation 
probably lies in the unusual distention of the uterus. 

Pain in the back and pelvis is complained of in nearly all cases, 
but does not usually develop until hemorrhage has persisted for 
some time. Not infrequently pain is absent until the hemorrhage 
is profuse and the cervix dilating. 

In extensive degeneration of the chorion the foetus dies early and 
is absorbed. We then have none of the physical evidences of a 
foetus. In partial degeneration of the chorion the development of 
the child may not be hindered, and there may be no clinical evi- 
dences of vesicular degeneration. 

The consistency of the uterus is a subject of some importance 
from a diagnostic point of view. Poten reported eleven cases of 
hydatiform mole, in three of which he observed irregular contrac- 
tions of the uterine wall. These contractions were localized over 
a limited area, and were transient, lasting but a few minutes and 
reappearing at variable intervals. To the examining finger they 
might easily be mistaken for intramural fibroids. Poten does not 
claim this is a reliable sign, but suggests that further investigation 
of the phenomenon be made. 

An early diagnosis of hydatiform mole is of importance because 
of the liability to malignant degeneration. While, as a rule, there 
will be the usual clinical signs of a mole some time before malignant 
changes develop, there is always the possibility of early malig- 
nant transformation, and it is not possible to detect these early 
malignant changes. Our only safeguard lies in the early recog- 
nition of the mole and in its immediate removal. 

Will the microscope supply an infallible means of making an 
early diagnosis of malignant degeneration of a mole ? We do not 



156 SPECIAL DIAGNOSIS. 

accept the statement of Van der Hoeven and Neumann that 
epithelial invasion of the stroma of the villi is the earliest and at 
all times reliable evidence of malignancy. As has been stated, such 
findings are not uncommon in normal pregnancy. Marchand failed 
to find the stroma invaded in a malignant mole, and Ruge found 
such invasion in an undoubted benign mole. In my second case 
there was epithelial invasion of the stroma of the villi. Two years 
have elapsed since the removal of the ruole, and no signs of malig- 
nancy have developed. 

In a case reported by Poten the mole went on to the time of full- 
term pregnancy. Neumann's cells were found in the stroma of the 
villi. On the twenty-sixth day after the mole was expelled hemor- 

FlG. 68. 



c* 



i #' 



@f 



Giant syncytial cells showing vacuoles. 

rhage recurred to a slight degree. The uterus was curetted, and a 
microscopic examination of the scrapings showed no evidence of 
malignant invasion ; recovery followed. This case shows how 
difficult, and at times impossible, it is to determine the character of 
an hydatiform mole. In the light of our present knowledge we 
must always make a guarded diagnosis in the early stage ; and at 
no time can a diagnosis be made with absolute certainty from the 
expelled mole. The invaded decidua, and if possible the underly- 
ing musculature, will alone afford evidences of malignant invasion 
prior to the development of metastasis. In the case reported by 
Schmidt a diagnosis of malignancy was first made from a micro- 
scopic examination of a metastatic growth which appeared in the 






DIAGNOSIS OF HYDATIFOBM MOLE. 157 

vagina. The uterus was not removed, and recovery followed the 
removal of the vaginal growth. When hemorrhage recurs days or 
weeks after complete removal of the mole the uterus should be 
curetted and the scrapings examined for active and extensive 
invasion of the uterine tissues. Large nuclei, rich in chromatin 
and mitotic figures, together with a tendency on the part of the 
protoplasm to separate into individual cells or chains of cells, is, 
according to Voigt and Gottschalk, suggestive of malignancy. 

We are forced to the conclusion that as yet we have no certain 
means of making an absolute and early diagnosis of malignant 
degeneration of an hydatiform mole. The clinical signs, together 
with the gross and microscopic appearances, are all to be carefully 
considered. In view of our inability to make an absolute early 
diagnosis, vesicular degeneration of the chorion, however limited, 
demands immediate interference, to be followed by a period of at 
least three years of watchful expectancy ; and if, at any time fol- 
lowing the expulsion of the mole, hemorrhage recurs, the uterus is 
to be curetted and a microscopic examination made of the scrapings. 

Regarding the prognosis of hydatiform mole, experience teaches 
us to look with suspicion upon all cases, even months and years 
after the removal of the mole. It is seldom that serious conse- 
quences occur while the mole is in utero. Malignant degeneration, 
rupture of the uterus, fatal hemorrhage — all these have occurred 
with the mole in situ, though such happenings are, fortunately, 
rare. We have learned to fear remote results — i. e., a repetition in 
subsequent pregnancies and malignant degeneration of retained 
chorio-epithelium. Heitzman estimated the mortality at 13 per 
cent. These statistics were gathered at a time when chorio- 
epithelioma malignum was not recognized. It is generally accepted 
that 10 per cent, of hydatiform moles undergo malignant degenera- 
tion. This estimate is generally accepted as approximately express- 
ing the death rate of hydatiform mole ; but it is far too small, as 
shown by the following data. Deaths from hemorrhage and, to a 
lesser degree, from septic infection and rupture of the uterus add 
materially to the death rate, bringing the mortality to near 25 per 
cent. 

In my 210 cases collected from the literature there were 49 deaths 
— a mortality of about 25 per cent. Of this number 32 died from 
syncytioma malignum (16 per cent.); 7 died from hemorrhage (4 
per cent.) ; 4 died from septic peritonitis (2 per cent.) ; 1 died from 



158 



SPECIAL DIAGNOSIS. 



general sepsis ; 1 from uraemia ; 1 from endocarditis and nephritis ; 
1 from meningitis, and 2 from unknown causes. The author does 
not regard these statistics as expressing actual facts. There is 
doubtless a tendency to report all cases resulting fatally and to 
overlook those having no special point of interest in their course 
and termination. 

The later in pregnancy we have to do with vesicular degenera- 
tion of the chorion the more grave the prognosis, because of the 
difficulty in removing the mole ; the greater liability to rupture of 
the uterus and to malignant degeneration. It has been stated, and 

Fig. 69. 




Showing syncytial invasion of the stroma. 

will bear repetition, that the removal of an hydatiform mole is 
imperative as soon as the diagnosis is established. There can be 
no temporizing, however limited the vesicular degeneration and 
however early or late the condition is recognized. Where but a 
small area of the placenta is involved the diagnosis is not made 
until the termination of pregnancy ; hence the question of inter- 
ference will not arise during pregnancy, but the same degree of 
watchful expectancy must be exercised after the termination of 
pregnancy. While all agree as to the disposition that should be 






DIAGNOSIS OF HYDATIFORM MOLE. 159 

made of the mole, it is always a grave question as to what should be 
our attitude toward the uterus after the mole is expelled. Solowiz 
has advised hysterectomy in all cases, and surely this would be the 
logical conclusion were we to agree with Van der Hoeven that all 
hydatiform moles are malignant. 

Recognizing the frequency of malignant degeneration of hydati- 
form mole, and finding our most reliable and early evidences in 
malignant invasion of the decidua, we indorse the advice of Butz, 
who would curette the uterus ten or twelve days after the expulsion 
of the mole, for the purpose of removing remaining foetal elements 
and of making a microscopic examination of the scrapings to 
detect a possible malignant invasion, as shown by active prolifera- 
tion of the chorio-epithelium. Doubt will occasionally arise after 
such a procedure, and where such doubt exists the uterus should 
be removed on suspicion. 

Respecting the influence of hydatiform mole upon future child- 
bearing, it is observed that healthy children are born subsequent 
to the expulsion of the mole, and that there does not appear to be 
acquired an added tendency to abortion. Contrary to the statement 
made by most text-books, it is the exception for a woman to give 
birth to more than one mole. In 210 recorded cases but two 
women gave birth to two moles, one to four (not recorded), one to 
five (not recorded), and one to eleven. It is furthermore seen that 
conception is possible very soon after the expulsion of the mole. 
On the other hand, a period of twenty years of sterility, and in two 
instances ten years, has preceded the development of the mole. 
It is correctly stated that multipara are more liable to hydatiform 
mole than primiparse. In the 210 cases, 42 were primiparse, 139 
multiparas, and 29 not recorded. 



CHAPTER XIX. 

THE DIAGNOSIS OF CHORIO-EPITHELIOMA MALIGNUM. 

From the fact that the histogenesis of this new-growth has until 
recently been little understood, a number of names have been 
assigned to it. It was called deciduoma malignum, because it was 
believed to be a malignant proliferation of the decidua. Sarcoma- 
chorio-cellulare was a name suggested, on the theory that the essen- 
tial cell structures were of mesoblastic origin. On the other hand, 
the name carcinoma syncytiale was proposed, because of the sup- 
posed epithelial character of the growth. The term chorio- 
epithelioma malignum more accurately expresses the true histogenesis 
of the growth, for it is now generally accepted that the growth is 
derived from the epithelial elements of the chorion and not from 
the decidua. 

We are indebted to Sanger for our first knowledge of this tumor 
formation. In 1888 Sanger described such a case before the 
Obstetrical Society of Leipzig. He, however, believed the growth 
to be a malignant proliferation of the decidua, and classified it as a 
sarcoma. 

L. Frankel was first to demonstrate the origin of the growth in the 
epithelium of the chorion. He classified the tumor as a carcinoma. 

The greatest and most important work on the subject is that of 
Marchand, to whom we are largely indebted for our present 
knowledge of the histogenesis and histology of chorio-epithelioma 
malignum. He it was who demonstrated that both the syncytium 
and Langhans' cells take part in the formation of the new-growth, 
and hence the foetal origin of the tumor, though occupying maternal 
tissues. 

Peters demonstrated the true genesis of the epithelial layers of 
the chorion, Langhans' layer and syncytium in his observations on 
an ovum five to six days old. He has demonstrated to the satis- 
faction of most observers that both the syncytium and Langhans' 
layers are derived from the ectoderm or trophoblasts, being his- 
togenetically identical. Holding to this view of the histogenesis 



DIAGNOSIS OF QUO RIO -EPITHELIOMA MALIGNUM. 161 

of Langhans' layer and the syncytium, we are prepared to enter 
into a more intelligent discussion of the histology of the growth. 

Etiology. Pregnancy either precedes or accompanies the devel- 
opment of chorio-epithelioma malignum, and is essential to its 
development. Hence it is that the lesion is only found in women, 
and that, too, during the period of sexual maturity. In my analysis 
of 210 cases of hydatiform mole, I find that 16 per cent, became 
malignant. It is stated that about 42 per cent, of chorio-epithelioma 
malignum cases follow the expulsion of an hydatiform mole, 32 
per cent, follow upon abortions, and 26 per cent, follow upon full- 
term labor. The time an hydatiform mole remains in utero has no 
influence upon the development of a malignant growth ; there is 
the same liability to malignant transformation in the early as in 
the later moles. 

In 124 cases collected by Ladinski the average age of the patient 
was thirty-two years — the extreme ages seventeen and fifty-five 
years. In 90 cases collected by the same author the average number 
of children born was 4.2 ; hence multipart ty has no influence upon 
the development of the growth. The time of the development of 
the growth in relation to the expulsion of an hydatid mole, an 
abortion, or a full-term labor is two weeks to four and a half years. 

Diagnosis. There is always a history of pregnancy and the 
expulsion of an hydatiform mole, an undeveloped foetus, or a full- 
term foetus, weeks, months, and even years before the appearance 
of a malignant growth. 

The earliest symptom is hemorrhage. The loss of blood increases 
in amount and frequency, and very early causes profound anaemia. 
The usual means employed to check hemorrhage fail utterly, and 
may increase the flow. In curettage, the procedure must some- 
times be abandoned because of the alarming hemorrhage. A dirty, 
watery discharge occurs, together with and in the intervals between 
hemorrhages. Later this discharge assumes a foul odor. 

Pain is not a notable symptom. When present it is usually 
referred to the thighs and sacral region. 

Cachexia is an early development following closely upon the 
ansemia. Loss of weight and strength are extreme. 

Symptoms referable to metastasis are early present — so early as to 
almost characterize the disease. In order of frequency metastatic 
growths are found in the lungs, vagina, liver, spleen, kidneys, 
ovaries, intestines, brain, broad ligament, pleura, lymphatic glands, 

11 



162 SPECIAL DIAGNOSIS. 

pancreas, heart, stomach, and lymph glands of the pelvis. It is 
unusual for the metastatic growths to spread by way of the lymph 
glands, as is common with carcinoma. The cellular elements are, 
as a rule, conveyed by the blood stream, and in this respect behave 
like a sarcoma. 

Fever of a low grade is commonly present, and may reach 
104° F. The pulse is correspondingly rapid and feeble. 

The above clinical signs are very significant, but not alone suffi- 
cient. The macroscopic and microscopic features of the growth 
must be considered before a diagnosis can be made with certainty. 

The macroscopic appearances of the growth are not character- 
istic. The uterus is almost always enlarged, and is commonly 
described as soft. In advanced cases there may be irregularities 
on the outer surface as well as on the inner. The cervix is usually 
patulous to the index finger, and in the cavity of the uterus may be 
felt a soft, brain-like mass, friable, and bleeding profusely when 
handled. To the naked eye this soft mass resembles at times 
placental tissue, and at other times a vascular sarcoma. The color 
of the growth is mottled red, varying from a bright to a dark 
shade. Necrosis early develops. The primary growth is not 
always confined to the uterus. Cases have been recorded where 
the uterus remained free and a chorio-epithelioma malignum 
developed in the vagina and lung. 

The microscope is indispensable in determining the true character 
of the growth. Under the microscope we recognize a rapidly pro- 
liferating structure composed of syncytium and Langhans' cells, 
which invade the uterine tissue in a most atypical manner and early 
extend to distant portions of the body by way of the blood stream. 

After the expulsion of an hydatid mole the uterus should be explored 
by the finger to detect and remove any retained placental tissue. Two 
weeks later the uterus should be curetted and the scrapings examined 
microscopically. If in the decidua Langhans' cells and the syncytium 
are found to be proliferating, the uterus should be removed without 
delay. In every abortion or full-time labor when an unaccountable 
hemorrhage follows weeks and months afterward, an exploratory curet- 
tage should be done, in view of the possible finding of malignant 
placental tissue. 

The microscopic picture is that of strands of protoplasmic masses, 
with nuclei and vacuoles forming a reticular structure. Polynu- 
clear giant cells of syncytium are found in the network. 



CHAPTEE XX. 

THE DIAGNOSIS OF MALFORMATIONS OF THE UTERUS. 

As stated by E. C. Dudley, the developmental defects of the 
uterus form a large proportion of the genital malformations. They 
are arranged under two general headings : 

1. Those due to imperfect development of M tiller's ducts. 

2. Those due to imperfect blending of the same. 

UTERUS DEFICIENS. 

It is very unusual to find in an adult a complete absence of the 
uterus. When found there is usually also an absence of the entire 
genital tract, or only a rudimentary development of the vulva, 
vagina, tubes, and ovaries. The round ligaments may be present, 
though poorly developed. If the ovaries are present the menstrual 
molimina will be experienced, and vicarious menstruation has been 
observed. There may or may not be sexual desire. 

The differential diagnosis between a complete absence of the 
uterus and a rudimentary uterus is scarcely possible without mak- 
ing an exploratory incision. Placing a sound within the bladder 
and directing an assistant to hold it while proceeding with a recto- 
abdominal examination will demonstrate either an entire absence 
or a rudimentary development of the uterus. 

UTERUS RUDIMENTARIUS. 

As the name implies, the uterus is rudimentary in its develop- 
ment. It remains as a fibromuscular body, ill-formed and under- 
sized. The walls may be so thin as to suggest the name uterus 
membranaceous. The cervix, adnexse, ligaments, and vagina are 
likewise rudimentary or absent. The external genitals may be 
well-formed, though this is not probable. As stated in the above 
paragraph, a diagnosis cannot be made from complete absence of 
the uterus unless by abdominal section. 



164 



SPECIAL DIAGNOSIS. 



UTERUS FCETALIS (Infantile Uterus). 

The uterus and adnexse fail to develop beyond that of foetal life 
or early infancy — they are undersized. Aside from the size, the 
most striking feature of the foetal or infant uterus is the dispro- 
portion between the cervix and body of the uterus. The cervix is 

Fig. 70. 




Normal position of the uterus. The uterus lies anteposed, anteverted, and slightly ante- 
flexed when the bladder and rectum are empty and the patient in the upright position. 



DIAGNOSIS OF MALFORMATIONS OF THE UTERUS. 165 

two-thirds the length of the whole organ, the body one-third. In 
the mature uterus the cervix is one-third the length of the whole 
organ, the body two-thirds. Again, the arbor vitse in the foetal or 
infantile uterus extends the entire length of the uterine cavity, 
while in the adult uterus the mucosa of the body is smooth and the 
arbor vitse extends only the length of the cervix. Still another 
feature of the foetal or infantile uterus is the absence of a fundus ; 
the top of the uterus is either flat or depressed, while in the adult 
uterus it is convex. 

Fig. 71. 




a. Ribbon-shaped rudiment of the uterus, b, b. Round ligaments, c, c. Fallopian tubes. 
d, d. Ovaries. (Mann.) 



The vagina is usually shorter and narrower than is normal, but 
may be well-formed. The vulva may be poorly developed and the 
breasts likewise. 

A general hypoplasia of the whole cardio-vascular system is said 
to be an underlying factor in this developmental failure. Chlorosis, 
scrofula, and the general wasting diseases are given as general pre- 
disposing causes. Cretins and dwarfs commonly possess foetal or 
infantile uteri. Not infrequently there is perfect general physical 
development. It is probable that the developmental failure lies 
primarily in the ovaries. 



166 SPECIAL DIAGNOSIS. 

The clinical diagnosis is not difficult. Primary amenorrhea 
should always suggest the probable existence of an infantile uterus. 
Sterility is invariably present. If the patient has menstruated 
normally, or if she has ever been pregnant, there is no possibility 
of an infantile or foetal uterus. A small vagina and vaginal por- 
tion of the cervix suggest a small uterus. A recto-abdominal exam- 
ination under anaesthesia is preferred. When the uterine canal will 
admit a sound the measurement of the length of the uterus may be 
made, and an estimate of the thickness of the wall can be arrived 
at by a conjoined recto-abdominal examination, the sound remaining 
in the uterus. 




Uterus, Fallopian tubes, and ovaries of an infant one month old. Natural size. (Dudley.) 

UTERUS UNICORNIS. 

But a single horn of the uterus is developed ; the opposite horn 
is either absent or rudimentary. 

The explanation of this defect lies either in a partial or complete 
failure of one Miillerian duct to develop. The single horn tapers 
off into the tube. At the juncture of the horn and the tube the 
round ligament is given off. There is no fundus. The vagina and 
cervix are small, and may be divided partially or completely by a 
septum. The ovaries and tubes may be rudimentary or absent ; 
so, also, the bladder and kidney may be undeveloped, or there may 
be absence of the kidney on the side opposite the single horn. 

Sterility is the rule, though pregnancy in a rudimentary horn is 



DIAGNOSIS OF MALFORMATIONS OF THE UTERUS. 167 



possible. Amenorrhea is common, but the menstrual functions may 
proceed regularly. Where pregnancy exists in a rudimentary horn 




Uterus unicornis. LH. Left horn. LT Left tube. Lo. Left ovary. EH. Right horn. ET. 
Right tube. Eo. Right ovary. ELr. Right round ligament. LLr. Left round ligament. 

(Mann.) 

Fig. 74. 




Uterus septus duplex (natural size), completely double uterus, and incompletely double 
vagina of a girl, twenty-two years of age. a, a. Tubes. 5, b. Fundus of the double uterus. 
c, c. c. Partition of uterus, d, d. Cavities of the uterine bodies, e, e Internal orifices. /, /. 
External walls of the two necks, g, g. External orifices, h, h. Vaginal canals, i. Partition 
which divided the upper third of the vagina into two halves. (Mann.) 



168 SPECIAL DIAGNOSIS. 

we have to deal with a condition not unlike tubal pregnancy in its 
clinical aspect. The dangers of rupture and of hemorrhage are 
the same. There is no way of making a distinction between these 
two conditions save by abdominal section, unless, as is possible in 
exceptional cases, the gestation sac is demonstrated by abdominal 
palpation to lie within the attachment of the round ligament. In 
tubal pregnancy the gestation sac lies external to the attachment 
of the round ligament. 

UTERUS SEPTUS (Bilocularis). 

The uterus is divided by a vertical septum extending a variable 
distance from the external os to the fundus. On the exterior there 
is no evidence of a septum. 

The uterus is broader and more globular than is the perfectly 
developed organ. Not infrequently the vagina is septate. Various 
explanatory terms have been applied to the several degrees of the 
septate uterus — i. e., uterus biforis supra simplex, where the septum 
is only found near the external os ; uterus subseptus unicorporens, 
where the septum is found in only a part of the cervix and 
body ; uterus subseptus unicellis, where the septum is found in the 
body, not in the cervix ; and uterus subseptus uniforis, where the 
septum completely divides the body and cervix, there being a single 
external os. 

UTERUS BICORNIS. 

The two horns of the uterus are united to a limited and variable 
degree, the union taking place from below upward. The degree of 
separation varies from completely divided bodies with a single 
cervix to a union of the two horns, leaving but a notch in the 
fundus. The two horns are not always of equal size, and may not 
lie on the same plane. A septum may partially or completely divide 
the cervix and vagina. One or both horns may be imperforate. The 
external genitals are usually normal. 

In addition to the anomalies in the development of the genital 
organs there may be maldevelopments of the urinary tract — e. g., 
ectopia vesicae, absence of or congenital atrophy of the kidney. 

The behavior of the uterus bicornis is similar to that of the 
uterus septus. Menstrual disorders are common. Amenorrhoea 
may result from atresia of the lower genital tract, or from an 



DIAGNOSIS OF MALFORMATIONS OF THE UTERUS. 169 

imperforate lumen in both horns of the uterus. The menses may 
flow simultaneously from the two horns or alternately at intervals 
of from two to four weeks. When one horn or one-half of a 
septate uterus is pregnant the opposite side may continue to men- 
struate or may become pregnant at any time during the period of 
gestation in the other side. A decidua may form in the non-gravid 
side and be discharged at labor. Pregnancy and labor may progress 
normally, and uterine contractions occur in both horns. This, how- 
ever, is not the rule. The uterine contractions are seldom regular 
and strong ; malpositions and malpresentations of the child are 
common ; placenta prsevia and premature detachment of the placenta 
may occur at any time, and rupture of the uterus during labor is 
always to be feared. 

The presence of a uterus bicornis or uterus septus is often not 
suspected, even after marriage and childbirth. A double vagina 
or a double cervix will suggest the presence of a septate or bicornate 
uterus. When pregnancy does not exist the finger or sound will 
aid in the diagnosis. Under anaesthesia the separate horn may be 
detected by bimanual examination. Involution is rarely so perfect 
in the puerperium as in the normal uterus, and there are likely to 
follow displacements and subinvolution with all their remote con- 
sequences. Placental tissue is liable to be retained in the uterus 
and lead to infection and hemorrhage. 

UTERUS DIDELPHYS (Uterus Duplex, Uterus Separatus). 

Not only the uterine horns but the cervix as well is completely 
divided. Each half is equipped with a single tube, ovary, and 
round ligament. The vagina may be single, double, or partially 
divided. The two halves may be in different planes and of unequal 
size. One or both sides may be imperforate. All that has been 
said of the clinical features of a bicornate uterus will apply to a 
uterus didelphys. 

UTERUS ACCESSORIUS. 

This is the rarest of anomalies in the development of the uterus. 
Hollander and Skene each observed a case in which a small uterus 
was situated in front of a normal uterus, the two bodies join- 
ing at the internal os. The accessory uterus had no adnexa and 
no round ligaments. The explanation of this anomaly is probably 



170 



SPECIAL DIAGNOSIS. 



that a diverticulum of Miiller's duct developed into an accessory 
uterus. Hollander's case gave birth to seven children. In an 
abdominal section placental tissue was found in the accessory 
uterus. Skene's case suffered from a leucorrhoeal discharge from 
the accessory organ. 




Uterus bicornis unicellis. a. Vagina laid open. b. Single cervix, c, c. Uterine horns. 
/,/. Round ligaments, d, d. Fallopian tubes, e, e. Ovaries. (Mann.) 



Fig. 76. 




Double uterus, uterus didelphys. a. Right cavity, b. Left cavity, c. Right ovary, d. 
Right round ligament, e. Left round ligament. /. Left tube. g. Left vaginal portion, h. 
Right vaginal portion, i. Right vagina, j. Left vagina, k. Partition between the two 
vaginae. (Mann.) 



CHAPTEK XXI. 

THE DIAGNOSIS OF MALPOSITIONS OF THE UTERUS AND 
ITS NEIGHBORING ORGANS. 

Under perfectly physiological conditions the uterus may occupy 
widely varying positions. In order that these physiological changes 
in position may occur, the uterine ligaments, pelvic peritoneum, 
and cellular tissue must possess their normal degree of elasticity. 
The normal position of the uterus varies with the attitude of the 
individual. It is crowded backward by a full bladder, forward by 
a loaded rectum, and forward and downward by increase in the 
intra-abdominal pressure from coughing, straining at stool, etc. By 
reference to Plate XX., fig. 2, it will be seen that the normal position 
of the uterus of a virgin in the erect posture, with the bladder and 
rectum empty, is one of anteversion, slight anteflexion, anteposition, 
and slight lateral position. The body of the uterus lies about 1 cm. 
behind the upper border of the symphysis pubis, the cervix points 
to the second sacral vertebra, and lies about 2 cm. in front of the 
sacrococcygeal articulation. In the virgin there is less anteflexion 
than in the multipara. The explanation lies in the fact that the 
small resisting vagina presses the slender cervix backward. 

Pathological changes in the position of the uterus and its neigh- 
boring organs are more or less permanent. There is no tendency 
toward a spontaneous return to the normal position. 

Pathological Mobility of the Uterus. The uterus becomes 
abnormally movable when the normal supports are weakened or 
have given way. A relaxation of the uterine ligaments, of the 
pelvic floor, and of the abdominal muscles will lead to abnormal 
mobility of the uterus. Under such conditions the uterus gravitates 
according to the position of the patient. In the upright position, 
with the bladder empty, it may fall forward and downward. In 
the dorsal position with the rectum empty the uterus falls back- 
ward into the hollow of the sacrum. 

Pathological Fixation of the Uterus. An abnormally movable 
uterus may lodge in a position where it becomes fixed and immov- 



i 



172 



SPECIAL DIAGNOSIS. 



able. It is thereby evident that the factors causing increased 
mobility of the organ may lead to a more or less permanent fixation. 
Fixation of the misplaced uterus will be considered in subsequent 
chapters. We will here discuss only fixation of the normally 



Fig. 77. 




Sagittal section of the female pelvis. (Testut.) 

placed uterus. By this we mean a uterus in normal position but 

lacking the degree of elasticity and mobility that is found in health. 

Parametritis atrophicans (Freund) or parametritis posterior 

(Shultze) is a condition frequently overlooked. The uterosacral 



PLATE XX. 

Fig. 1. 




Anteposition of the uterus. A retro -uterine hematocele fills the 
eul-de-sae of Douglas and the space between the uterus and sacrum. 
The uterus is crowded forward. 

Fig. 2. 




Anteposition. The loaded rectum crowds the uterus forward into 
anteposition when the bladder is empty. The eul-de-sae of Douglas 
is almost obliterated. When the rectum is empty the uterus will fall 
back into the normal position. 



DIAGNOSIS OF MALPOSITIONS OF THE UTERUS. 173 

ligaments are firmly contracted and tender to pressure. By thick- 
ening and contraction of the uterosacral ligaments the cervix is 
drawn backward and the whole uterus restricted in its movements. 
A chronic metritis will diminish the normal flexibility of the 
uterus, as will also carcinoma and fibroids. Chronic cervical 
catarrh may stiffen the cervix. 

ANTEPOSITION. 

Anteposition is an exaggeration of the normal position. The 
uterus lies immediately behind the abdominal wall and symphysis 
pubis. Among the causes of anteposition of the uterus we have 
swellings behind, crowding the uterus forward, or adhesions attached 
to the anterior surface of the uterus pulling it forward. The latter 
condition is very unusual. The most common causes are tubal and 
ovarian swellings lying in the cul-de-sac of Douglas, retro-uterine 
hematocele, tumors of the uterus bulging from the posterior surface 
of the uterus, and new-growths of the rectum. Anteposition is often 
combined with elevation, anteversion, and anteflexion. 

The diagnosis is seldom difficult. On bimanual examination the 
uterus is found lying close to the anterior abdominal wall. When 
caused by a retro-uterine swelling which cannot be outlined apart 
from the uterus the sound will be required to locate the position of 
the organ. A retro-uterine tumor crowding the uterus forward is 
recognized by its irregular outline and its consistency. Here, again, 
the uterine sound will be of service in locating the uterus. In every 
doubtful case an anaesthetic should be administered. The one symp- 
tom commonly present is frequent urination. (See Plate XX.) 

In retroposition the uterus lies back of the normal position with- 
out change in the direction of its long axis. 

RETROPOSITION. 

As causes of retroposition we find either a swelling in front of 
the uterus or adhesions behind it. Among swellings in front of the 
uterus we find uterine fibroids, tumors of the bladder and anterior 
abdominal wall, and, occasionally, distended tubes and ovaries. 
Adhesions behind the uterus causing retroposition are largely con- 
fined to the peritoneal cavity, and involve the greater portion of the 
posterior surface of the uterus. These adhesions most frequently 



174 SPECIAL DIAGNOSIS. 

result from extension of an inflammation from the tubes, which, 
when inflamed, commonly lie behind the uterus. In abnormal 
mobility of the uterus due to a relaxation of the normal supports 
the uterus falls into retroposition when the patient lies upon her 
back. (See Plate XXI.) 

It is most important to recognize the cause of the displacement, 
inasmuch as retroposition per se is of little clinical significance. 
When no tumor mass or adhesions are found in the pelvis and the 
retroposed uterus displays an abnormal mobility the displacement 
is regarded as due to relaxation of the uterine supports. 

It is not always possible to diagnose the presence of adhesions, 
even when the examination is made under anaesthesia. All 
operators of experience will testify to the frequency with which 
perimetritic adhesions are unexpectedly found after opening the 
abdominal cavity. 

Perimetritic adhesions are confined to surfaces normally covered 
with peritoneum. They are found with greatest frequency about 
inflamed tubes and ovaries, and are therefore most commonly located 
beside or behind the uterus. The uterus is rarely absolutely fixed. 
The degree of mobility depends upon the location of the adhesions, 
their extent, length, and firmness. Adhesions binding the uterus 
to movable structures, such as bowel and omentum, usually permit 
more or less mobility on the part of the uterus. The diagnosis 
of a perimetritic exudate — that is, of an exudate lying within the 
peritoneal cavity and binding together the peritoneal surface of 
the uterus with the peritoneal surface of the adjacent structures 
from an exudate involving the pelvic cellular tissue — is made 
first of all by the location. A parametritic exudate lies low in the 
pelvis in close proximity to the vaginal wall, while a perimetritic 
exudate lies on a higher plane and is more difficult to palpate 
through the vagina. Furthermore, in parametritis the adhesive 
bands are firmer and larger than in perimetritis. The uterine 
sound may be of service in locating the position of the uterus apart 
from inflammatory exudates and new formations. 

LATEROPOSITION. 

Lateroposition is generally combined with retroposition, less often 
with anteposition and descensus. A limited lateral displacement of 
the uterus may be regarded as normal, and is explained by a short- 



PLATE XXI, 

Fig. 1. 




Retroposition of the uterus. The distended bladder crowds the 
•uterus backward into retroversion and retroposition. When the 
bladder is empty the uterus will fall forward into anteversion and 
anteposition. 

Fig. 2. 




Retroposition of the uterus. Peritoneal adhesions bind the pos- 
terior surface of the uterus to the sacrum and rectum, holding the 
uterus firmly in retroversion and retroposition. 



DIAGNOSIS OF MALPOSITIONS OF THE UTERUS. 



175 



ening of the broad ligament on the side to which the uterus leans. 
This congenital unilateral shortening of the broad ligament and also 




Left laterodisplacement of the uterus. The left broad ligament is thickened and contracted 
and has drawn the uterus to the left. 




Left lateroversion of the uterus. The uterus is crowded to the left side of the pelvis, the 
long axis of the uterus inclines to the left. The cause of the displacement is a broad liga- 
ment cyst of the right side adherent to the wall of the pelvis. 

of the uterosacral ligament accounts for the lateral displacement of 
the uterus not infrequently found in virgins. 



176 SPECIAL DIAGNOSIS. 

The usual causes of lateral displacements of the uterus are 
inflammatory exudates and new formations ; more rarely cica- 
tricial contractions of the vaginal wall following lacerations and 
sloughs. Exudates at the sides of the uterus, when large, will 
crowd the organ to the opposite side of the pelvis. Later, as the 
exudate organizes and contracts, the uterus is drawn to the side 
occupied by the exudate (Fig. 78). If the exudate exerts its 
influence along the entire side of the uterus, as in Fig. 79, the 
uterus as a whole will be first pushed to the opposite side and later 
drawn to the same side. If the exudate involves the lower segment 
of the broad ligament, leaving the body of the uterus free and mov- 
able, the cervix will be drawn toward the side in which the exudate 
has collected and the body of the uterus tilted to the opposite side 
— a latero version or lateroflexion . Likewise, in case of tumor for- 
mations lying beside the uterus, if the force is distributed along the 
side of the uterus there will be a simple lateroposition ; if pressure 
is exerted upon the fundus alone, there will be a lateroversion or 
flexion in which the body will be crowded to the opposite side, the 
cervix pointing to the side occupied by the tumor (Fig. 79). 

Slight lateral displacements of the uterus are commonly over- 
looked. When found they should always lead to a careful bimanual 
examination, and, if necessary, under ansesthesia, in view of deter- 
mining the cause of the lateral position. Eeference to Figs. 78 
and 79 will suggest in a general way the mechanism of the dis- 
placement. In a word, the displacement is due to traction on the 
one side or to crowding on the other. 

ELEVATIO-UTERI. 

In elevatio-uteri the uterus is raised above the normal plane and 
approaches the anterior abdominal wall. In uncomplicated elevatio- 
uteri the long axis of the uterus is straightened. As a matter of 
fact, it is unusual to find an uncomplicated elevation of the uterus, 
such a condition being, as a rule, associated with lateral, anterior, 
or posterior displacements. The position is physiological in preg- 
nancy. The extent to which the uterus may be drawn upward is 
astonishing. A perfectly normal uterus may be raised to the level 
of the umbilicus. 

Causes of elevation of the uterus may be classified under two 
general heads, namely, swellings below the uterus crowding it 



PLATE XXII. 

Fig. 1. 




Retroposition of the uterus. The uterus is drawn backward into 
retroposition by peritoneal bands of adhesions extending from the 
supravaginal portion of the cervix to the sacrum. 

Fig. 2. 




Klevatio-uteri following a ventrosuspension of the uterus. Ad- 
hesions unite the fundus of the uterus to the abdominal wall and 
retain the uterus in an elevated position. 



DIAGNOSIS OF MALPOSITIONS OF THE UTERUS. 177 

upward, or tumors and adhesions making upward traction upon the 
uterus. 

Swellings beneath the uterus and crowding the uterus upward 
are tumors of the cervix, vagina, rectum, and hematocele. Adhe- 
sions binding the fundus to the abdominal wall may develop during 
pregnancy and the puerperium, leaving the uterus in elevation 
after the puerperium Fig. 78 represents the uterus suspended 
from the abdominal wall in an elevated position. A Cesarean 
section had been performed, and subsequently adhesions developed 
between the scar in the abdomen and that of the uterus. 

Fig. 135 represents a subperitoneal fibroid attached to the fundus 
and growing into the abdominal cavity. In this case either the 
pedicle must elongate or the uterus will be drawn upward, since 
the tumor, when it can no longer be accommodated in the pelvis, 
rises into the abdominal cavity. 

Tumors of the ovary with short pedicles may operate similarly to 
the fibroid in Fig. 80. The vagina will be found greatly elongated 
and the cervix may not be within reach of the examining finger. 

TORSION OF THE UTERUS. 

In torsion of the uterus the organ is twisted upon its long axis. 
This displacement rarely exists singly, but is generally associated 
with anteposition, lateral position, or elevation. Within perfectly 
normal limits the uterus is slightly turned upon its long axis, due 
to a shortening of the broad ligament, which runs outward and 
slightly backward. 

Causes of torsion may be traction on the one hand or pressure on 
the other. Adhesions running from the side of the uterus back- 
ward or forward may turn the uterus upon its long axis, as will 
also pressure made upon the side of the uterus by tumor formations. 

Fig. 79 represents a pedunculated ovarian tumor lying in the 
abdominal cavity. The tumor has been turned upon its long axis, 
and with it the uterus has become twisted. It is even possible for 
the uterus to be severed by the twisting. The blood supply to the 
uterus may be shut off completely and cause gangrene, or partially 
and result in atrophy. Menstrual and intermenstrual secretions 
may be pent up in the uterus above the point of torsion. 

As a rule, the displacement is not discovered until an exploratory 
incision is made to remove the cause. 

12 



178 



SPECIAL DIAGNOSIS. 

Fig. 80. 




Torsion of the uterus caused by twisting of the pedicle of an ovarian cyst. 

PROLAPSUS UTERI. 

As suggested by Berry Hart, prolapsus uteri should be considered 
under the head of displacement of the pelvic floor. The displace- 
ment should be regarded as a hernia of the uterus, adnexa, bladder, 
rectum, and vagina. While the author is in accord with this view, 
it is thought best to consider the subject along Avith other displace- 
ments of the uterus, as is the custom with most text-books. Web- 
ster, in his text-book on Diseases of Women, holds that prolapsus 
of the uterus, vagina, urethra, and bladder is the result of failure 
on the part of the fascial and other tissues supporting these organs 
between the bony walls of the pelvis to resist intra-abdominal 
pressure and gravity. If the power of resistance is weakened, or 
the intra-abdominal pressure and weight of the uterus are increased, 
or if both factors co-operate, prolapsus will occur. Webster takes 
exception to the view of Hart, who regards the perineum as a fixed 



DIAGNOSIS OF MALPOSITIONS OF THE UTERUS. 179 

segment for the support of the uterus, and of Thomas, who holds 
that the perineum is a supporting wedge. By anatomical dissec- 
tions Webster has demonstrated that the pelvic fascia and not the 
perineum and levator ani muscle is the real support. 

The various fascial tissues which meet in the perineum and give 
support to the pelvic viscera are : 1. The anterior and posterior 
triangular ligaments. 2. The visceral layer of the rectovaginal 
fascia. 3. The anal fascia. 4. The deep superficial fascia. Webster 
holds that the perineal muscles are of little value as a support com- 
pared to the pelvic fascia. 

In the absence of actual rupture of the fascia it is possible for 
stretching alone to so weaken the support that prolapsus will occur. 

Prolapsus uteri is a term implying not only a descent of the 
uterus, but also involvement of the bladder, rectum, vagina, and 
adnexa. Descent of the uterus may be checked at any point 
between the normal position and extreme prolapse. 

Nomenclature. With Webster, the author will speak of (1) 
descensus uteri, when the uterus and vaginal walls do not descend 
beyond the vulvar outlet, and (2) prolapsus uteri, when the uterus 
and vagina descend beyoud the vulvar outlet. 

The posture of the patient most favorable to recoguition of a 
downward displacement of the uterus is the erect (Fig. 7). In 
the recumbent position the uterus may resume in part or wholly 
the normal position. The erect position is awkward and embar- 
rassing, and for these reasons is seldom used. With the patient in 
the lithotomy position, the uterus may be manipulated in such a 
manner as to effectively demonstrate the degree of descensus. 
Bimanual manipulation, and, if necessary, traction upon the cervix 
with a vulsella forceps, will bring the uterus down to its maximum 
degree. Under normal conditions it is not possible to draw the 
vaginal portion of the cervix beyond the vulvar outlet. 

Anatomical Diagnosis. The diagnosis is almost wholly based 
upon the anatomical findings. It is at times possible to make a 
diagnosis from inspection alone. 

Inspection of the vulva may disclose the uterus and vaginal walls 
protruding from the vulvar outlet. In nearly all such cases the 
perineum is lacerated, and there may be a prolapsus of the mucous 
membranes of the urethra and rectum. 

Displacement of the Vagina. Inasmuch as the uterus is seldom 
displaced downward without a primary or secondary involvement 



180 SPECIAL DIAGNOSIS. 

of the vagina, we will first consider descensus and prolapsus of the 
vagina. 

1. Descensus vaginae implies a downward displacement of the 
vagina to a point short of the vulvar outlet. Preceding the descent 
of the vaginal walls there is usually a relaxation or laceration of 
the pelvic floor. As a rule, the anterior wall of the vagina is first 
to descend ; then follows the uterus as it is pulled upon by the 
sagging wall of the vagina, and, finally, the uterus in turn carries 
with it the posterior wall of the vagina. It is unusual for the 
anterior and posterior walls of the vagina to descend simultaneously 
and equally. Yet more unusual is the primary descent of the 
posterior vaginal wall. A limited degree of descensus vaginae may 
exist without displacing the uterus. The descent occurs from 
below upward ; seldom from above downward. 

2. Prolapsus vaginae implies a protrusion of the vaginal walls 
beyond the vulvar outlet, and is always associated with downward 
displacement of the uterus. In primary descent and prolapse of 
the uterus the vaginal walls are inverted from above downward, 
there being no pouching of the vaginal walls as in secondary 
prolapse of the uterus. The lower segment of the vaginal wall 
may prolapse, the upper segment invert, and the intervening one 
remain unchanged. The prolapsed anterior vaginal wall pouches 
into the vagina, dragging the bladder with it, and forming what is 
known as a cystocele. The bladder is so intimately attached to the 
anterior wall of the vagina it is quite impossible for the vagina to 
descend without carrying the bladder with it. The vaginal wall 
loses its usual elasticity, becomes glistening, dry, and leathery. 
Decubitus ulcers may form and show little tendency to heal. Between 
the posterior wall of the vagina and the rectum there is not that 
intimate attachment found between the bladder and vagina — a fact 
which explains why, in prolapse of the posterior vaginal wall, the 
rectum does not always descend with the vagina (rectocele.) 

Descensus and prolapsus vaginae are recognized by inspection and 
palpation of the vagina. Holding the labia apart the vaginal poach 
with its transverse folds is seen to bulge into the introitus. Inver- 
sion of the vagina is recognized by a corresponding shortening of 
the vaginal wall, together with a descent of the uterus. 

Displacements of the Uterus. After inspection and palpation 
of the vulva and vagina, the position of the uterus is to be deter- 
mined. The vaginal walls may be prolapsed to an unusual degree 



PLATE XXIII. 

Fig. 1. 




Primary prolapse of the uterus. The uterus lies wholly outside 
the vulva. The vaginal walls are completely inverted ; the cervix is 
not elongated. 

Fig. 2. 




Secondary descent of the uterus. The uterus is retroverted and 
lies on a plane lower than normal. The cervix does not extend to 
the vulvar outlet. The anterior vaginal wall is prolapsed, and the 
posterior vaginal wall is partially inverted. 



DIAGNOSIS OF MALPOSITIONS OF THE UTERUS. 181 

without altering the position of the uterus, though this is rare. 
Having observed a prolapse of the vagina we expect to find a 
secondary descent of the uterus. The descent of the uterus may be 
either primary or secondary. 

1. Primary descent and prolapse of the uterus are commonly the 
result of relaxed uterine supports, of added weight to the uterus, or 
of increase in the intra-abdominal pressure. As the uterus descends 
the anterior and posterior walls of the vagina become inverted from 
above downward, and near the outlet of the vagina the walls are 
relaxed. In exaggerated cases the vaginal walls may be completely 
inverted, thereby permitting the uterus to protrude beyond the 
vulvar outlet. (See Plate XXIII., Fig. 1.) 

2. Secondary descent and prolapse of the uterus follow upon a 
primary prolapse of the vaginal walls. As the walls of the vagina 
descend, traction is made upon the uterus at the point of attachment 
of the vagina. If the supports of the uterus offer little or no 
resistance, the walls of the vagina, assisted by gravity and intra- 
abdominal pressure, will bring about a descent of the uterus. If, 
however, the normal supports of the uterus, assisted by adhesions 
and new-growths, retard the descent of the uterus, there will result 
an elongation of the cervix in its supravaginal portion. Further- 
more, since the anterior wall of the vagina is first to prolapse, the 
anterior lip of the cervix will be elongated to a greater degree than 
will the posterior lip. If there is a simultaneous prolapse of both 
vaginal walls, the two lips of the cervix will be equally elongated. 
Hence, it is that in secondary prolapse of the uterus there is usually 
an elongation of the cervix, while in primary prolapse there is no 
such change. 

In complete prolapsus uteri, with inversion of both walls of the 
vagina, the cervix having been previously elongated, will retract 
more or less and may be materially shortened. The direction of 
the long axis of the uterus varies with the descent. The usual 
position in descensus uteri, when the uterus lies in the pelvis, is that 
of retroversion, and this position is exaggerated as the uterus 
descends. 

The adnexce are drawn down by the uterus, and in complete 
prolapsus are found in a funnel-like depression formed of perito- 
neum. 

The bladder is so intimately connected with the anterior vaginal 
wall and cervix that it must necessarily share in the displacement 



182 



SPECIAL DIAGNOSIS. 



of the uterus. As the anterior wall of the vagina pouches it 
drags upon the base of the bladder. In this manner a cystocele 
is formed, which, in complete prolapsus of the vagina, may include 
the greater portion of the bladder, causing it to protrude from the 
vulvar orifice. The exact limitations of a cystocele are determined 
by the catheter or sound. 

Fig. 81. 




Prolapsus uteri. The external os is lacerated and eroded. On the side of the prolapsed 
uterus is a decubitus ulcer. (Case of J. C. Webster's.) 



When the bladder is distended the cystic mass is felt and seen to 
protrude into the vagina, and its outlines are usually determined by 
inspection. 

The rectum is more loosely connected with the vaginal wall than 
is the bladder. The loose connective tissue may permit a complete 
prolapse of the posterior wall of the vagina without displacing the 
rectum. More often there is a pouching forward of the rectum into 



DIAGNOSIS OF MALPOSITIONS OF THE UTERUS. 183 

the vaginal pouch (rectocele). By direct palpation through the 
rectum the location and extent of the rectocele are determined. 

The anatomical changes occurring in the prolapsed tissues are 
largely the result of disturbance in circulation, of exposure to the 
influence of air, and of friction of the thighs. There is first conges- 
tion and oedematous infiltration, and this is followed by induration 
(hyperplasia) of the tissues. Decubitus ulcers, slow in healing, 
may form on exposed surfaces. Where the lips of the cervix 
are retracted, the exposed mucous membrane of the cervix may be 
transformed into stratified epithelium. 

Clinical Diagnosis. The diagnosis of descensus and prolapsus 
uteri is seldom difficult. It is very unusual to find a prolapsed 
uterus in a nullipara. Byea estimates that prolapsus uteri in nul- 
liparae occurs in not more than one per cent, of all cases. 

When upon physical examination the pelvic floor is found relaxed 
or lacerated, and there is also found a retocele and vesicocele, it is 
highly probable that the uterus will be found more or less pro- 
lapsed. A positive diagnosis can only be made by locating the 
fundus of the uterus in a bimanual examination. The patient 
being under anaesthesia, firm traction upon the cervix with the 
vulsella forceps will determine the exact extent of the displace- 
ment. The finding of the cervix at a lower level than is normal 
will not suffice for a diagnosis. Such a finding is not seldom due 
to an elongation of the cervix, either with or without a descent of 
the uterus. Without having located the fundus it cannot be said 
that the uterus, as a whole, has descended. By a rectal examina- 
tion it is often possible to locate the point of juncture of the 
cervix and uterine body, and estimate with some degree of accuracy 
the length of the cervix. Measuring the depth of the uterus by 
the sound will give exact information. 

It is more difficult to determine whether it is the supravaginal or 
infravaginal portion of the cervix that is elongated. This is ascer- 
tained by noting the depth of the vault of the vagina. If decreased 
in depth, the supravaginal portion of the cervix is elongated ; if it 
remains at the normal level, the infravaginal portion of the cervix 
is elongated. Both the infravaginal and supravaginal portions of 
the cervix may be increased in length, in which event there will be 
little change in the depth of the vault of the vagina. 

When the uterus is completely prolapsed, it is possible to approx- 
imate the hands over and above the body of the uterus, having 



184 



SPECIAL DIAGNOSIS. 



merely the vaginal walls and bladder between the fingers. By so 
doing it is possible to absolutely exclude all other conditions. 

Can the displacement of the vagina and uterus be corrected® 
This question will naturally arise before the diagnosis is complete. 
An attempt to replace the uterus may be made without anaesthesia, 
but where there is much tenderness or where great difficulty is 
encountered an anaesthetic should be given. Among hinderances to 
the replacement of the uterus may be mentioned pelvic tumors, 



Fig. 82. 




Bimanual palpation of the prolapsed uterus. 

adhesions, inflammatory exudates, and swelling from oedema and 
induration of the uterus and vagina. 

While the clinical symptoms cannot be relied upon in the diag- 
nosis of prolapsus uteri, they are fairly constant and deserve con- 
sideration. 

Backache is the most common complaint, but is more often due 
to diseases of the adnexse and to inflammatory exudates complicating 
prolapsus. 



DIAGNOSIS OF MALPOSITIONS OF THE UTERUS. 



185 



Feeling of weight, pressure, and traction is to be accounted for 
by the increased size of the uterus, by pressure upon neighboring 
structures, and by traction upon adhesions and the natural supports 
of the uterus. 

Leucorrhoea and menorrhagia are the result of passive congestion 
of the uterus, which in turn is the result of the displacement. 



Fig. 83. 




Prolapse of the third degree. Uterus protruding through the vulva. Sounds demonstrate 
the bladder to be in complete descent with the uterus. (Schaffer ) 



Sterility is due to mechanical hinderances and to complicating 
lesions in the uterus and adnexse. Pregnancy in a prolapsed uterus 
will either terminate spontaneously or go on to full term. Abortion 
is most likely to occur about the fourth month, when the pregnant 
uterus can no longer be accommodated in the limited space of the 
pelvis. If, however, the uterus does rise into the abdominal cavity, 
the prolapsus is relieved for the period of pregnancy. Involution 
in the puerperium is likely to be retarded, and the lochial discharge 
may remain bloody an unusually long time. 



186 



SPECIAL DIAGNOSIS. 



Disturbances of the bladder functions are almost constant, and are 
explained by pressure upon the bladder and the displacement of the 
bladder and urethra. Retention of the urine is possible even to 
the poiut of rupture. Cystitis may develop. 

The rectal functions are generally disturbed, though not to the 
extent and frequency found in the case of the bladder. Constipa- 
tion, rectal tenesmus, and hemorrhoids are the result of pressure 
made upon the rectum by the prolapsed uterus. 



Fig. 84. 




Prolapse of the third degree. Retroflexed uterus protruding through the vulva. Fundus 
covered hy the posterior vaginal wall. (Dudley.) 

Differential Diagnosis. Prolapsus uteri is most often confused 
with an elongated cervix. The differential diagnosis has been 
considered in a previous paragraph. The vaginal portion of the 
cervix may be so enormously enlarged as to resemble a prolapsed 
uterus. 

Complete prolapsus uteri with atresia of the cervix may be mis- 
taken for an inverted uterus. The finding of the fundus will clear 
up the diagnosis. 



PLATE XXIV. 

Fig. 1. 




Secondary prolapsus uteri with elongation of the cervix. Both 
vaginal walls are completely inverted. The cervix protrudes from 
the vulva. Neither the bladder nor the rectum are found in the pro- 
truding structures. 

Fig. 2. 




Complete inversion of the uterus. 



DIAGNOSIS OF MALPOSITIONS OF THE UTERUS. 187 

A large cyst of the vagina may protrude from the vulva, and on 
superficial examination be mistaken for a prolapsed uterus. Such 
cysts do not lie in the median line ; they fluctuate, and are covered 
with thin mucous membrane. A recto-abdominal examination, 
under anaesthesia if necessary, will enable the examiner to locate 
the body of the uterus in its normal position. 

A pedunculated submucous fibroid protruding into the vagina, 
or a pedunculated fibroid of the cervix, may be mistaken for a 
prolapsed uterus. The absence of the external os in the advancing 
body, the finding of the fundus within the pelvis at its normal 
level, and the passage of a sound into the uterine cavity will clear 
the diagnosis. 

INVERSION OF THE UTERUS. 

Inversion of the uterus is the partial or complete turning inside 
out of the organ. 

Etiology and Mechanism. Puerperal inversion is by far the 
most common form. It occurs in the puerperium nine times more 
frequently than at any other time. Traction upon the cord in 
retained placentae is the usual way by which the accident occurs. 
(See Plate XXIV., Fig. 2.) 

In 192,000 labors at the Rotunda Hospital in Dublin, but one 
case is reported. Kehrer's estimate is 1 in 2000 labors. The one 
essential condition in all inversions of the uterus is atony of the 
musculature in some part of the uterine body. Predisposing factors 
to atony of the uterus are frequent childbearing, protracted labors, 
hydramnios, twin pregnancy, precipitate labors, and repeated mis- 
carriages. With these conditions operating to fatigue and relax 
the uterine musculature, it only needs such procedures as traction 
upon the cord and compression of the fundus to effect an inversion. 

Spontaneous inversion may occur during or immediately follow- 
ing the third stage of labor, the mechanism being not unlike that 
of intussusception of the bowels. Of 100 cases of inversion of the 
uterus collected by Beckmann, 54 were spontaneous, 21 were 
directly caused by traction upon the cord, and 25 were from 
unknown causes. Of the spontaneous cases many were accounted 
for by the presence of short cords or cords twisted about the neck of 
the foetus. Immediately upon expulsion of the child a vacuum is 
created in the uterus, and, if in addition there is atony of the 
fundus, the intra-abdominal pressure may produce an inversion. 



188 



SPECIAL DIAGNOSIS. 



It is difficult to account for inversions occurring late in the puer- 
perium. Those due to tumor formations in the body of the uterus 
are of rare occurrence. Such tumors operate first by weakening 
the uterine wall, and, second, by making traction upon the atonic 
area. Pedunculated fibroids arising from the fundus are forced 
through the cervix into the vagina by the contractions of the 
uterus. If there is a relaxation at their point of insertion this 
action may cause an inversion of the fundus. 



Fig. 85. 



Fig. 86. 





Beginning inversion of uterus, placenta 
attached. (Modified from Ribemont-Des- 
saignes and Lepage.) 



Cup-shaped depression of fundus. (Modi- 
fied from Ribemont-Dessaignes and Le- 
page.) 



Therefore, we may divide inversion of the uterus from an 
etiological point of view into : 

1. Puerperal inversion. 

2. Inversion due to tumor formations. 

Olshausen reported a case of inversion in a girl, aged eighteen 
years. There was no assignable cause. This is one of the very 
few cases of spontaneous inversion occurring independent of labor 
and new-growths. 



DIAGNOSIS OF .MALPOSITIONS OF THE UTERUS. 



189 



Anatomical Diagnosis. Three grades of inversion are recog- 
nized : 

1. Where the fundus lies within the uterine cavity. 

2. Where the fundus lies within the vagina. 

3. Where the entire uterus protrudes from the vulva. 

In the depression formed by the inverted fundus are found the 
tubes, ovarian ligaments, and part of the round and broad ligaments. 
The ovaries are rarely found within the depression. The mucosa 



Fig. 



Fig. 88. 





Partial inversion oi uterus. (Modified from 
Ribemont-Dessaignes and Lepage.) 



Complete inversion of uterus. (Modified from 
Ribemont-Dessaignes and Lepage.) 



covering that portion of the inverted fundus lying within the 
vagina and external to the vulva undergoes retrogressive changes. 
In the beginning there is marked congestion ; later erosions and 
true ulcers may develop, and the covering of columnar epithelium 
may be converted into many layers of stratified squamous cells. 

Sloughing and gangrene of the inverted uterus may result from 
interference with the circulation. 

Following the congestion of the inverted body is an enlargement 
of the uterus from hyperplasia, which, when of long standing and 



190 



SPECIAL DIAGNOSIS. 



far advanced, may prevent replacement of the inverted fundus. 
From the tubes infections may travel to the ovary, pelvic connec- 
tive tissue, and peritoneum. Adhesions may bind together the 
tubes, ovaries, and coils of intestines within the funnel-shaped 
depression. 

Clinical Diagnosis. The diagnosis can only be made with cer- 
tainty by a physical examination. Subjective signs awaken no 
more than a suspicion of the accident. The inversion may take 



Fig. 89. 




The inverted uterus U, lying in the vagina V, is cut open to show the peritoneal sac, which 
does not contain the ovaries 0. Bristles are passed into the uterine orifice of the tubes. &. 
Broad ligament, r, r. Round ligament. T, T. Tubes. (Hart and Barbour.) 



place suddenly or slowly, and is referred to as acute or chronic. 
There is a sensation of something giving way in the pelvis, and 
this is immediately followed by hemorrhage. The loss of blood 
may result fatally, or may be limited in amount and merely prolong 
the menstrual flow. In the intervals of the bloody flow there is a 
profuse serous or seropurulent discharge. Partial inversion may 
occasion no symptoms and may escape notice. The functions of 
the bowel and bladder are disturbed, and general physical exhaus- 
tion follows. 



DIAGXOSIS OF 3IALP0SITI0XS OF THE U TEE US. 



191 



Under favorable conditions for making a bimanual examination 
it is possible to demonstrate by the band over the abdomen or in 
the rectum the absence of the fundus and in its place a funnel- 
shaped depression. By the fingers in the vagina the inverted 
fundus is felt bulging into the cavity of the uterus, into the vagina, 
or beyond the vulvar outlet. A sound placed within the bladder 
may assist as a guide in the bimanual examination. The finger in 
the rectum mav be made to meet the sound in the bladder or the 



Fig. 90. 



Fig. 91. 




Partial inversion of the uterus : the in- 
verted fundus lies within the cavity of the 

uterus. 




The uterus is divided by a septum from 
the fundus to the internal os. 



hand on the abdomen, thereby demonstrating the absence of the 
uterine body. 

In the protruding fundus are seen the tubal openings, there being 
no external os. AVhere the inversion is not complete the cervix 
may form a contraction ring about the presenting fundus. 

By drawing upon the fundus with oue hand, the fingers of the 
other hand in the rectum mav be hooked over the margin of the 
funnel-shaped depression. 

A sound passed into the vagina and between the protruding 
fundus and cervix will extend a limited distance and equally so 



192 



SPECIAL DIAGNOSIS. 



around the entire circumference. In puerperal inversion the free, 
rounded, bleeding mass, with its soft, shaggy surface protruding into 
the vagina, should suffice for a diagnosis when associated with the 
disappearance of the usual abdominal tumor. 

Differential Diagnosis. Pedunculated fibroids and polyps lying 
within the vagina are to be differentiated from inversion of the sec- 
ond degree by locating the fundus of the uterus within the pelvis by 
a recto-abdominal examination ; second, by passing a sound into the 
uterus and rinding the cavity of normal or increased depth ; third, 
by the absence of tubal openings in the protruding mass. 

Submucous polyps and fibroids lying within the cavity of the uterus 
show by the passage of the sound an increase in the depth of the 



Fig. 92. 




Complete inversion of the uterus. 



cavity of the uterus, and by a recto-abdominal or by a vagino- 
abdominal examination the fundus is located within the pelvis. 
Care must be taken in passing the sound that the growth does not 
obstruct the passage of the instrument, giving the impression that 
the uterine cavity is shortened. 

A partially divided uterus with a depression in the fundus may, in 
the passage of the sound and palpation of the fundus, give the 
impression of a partial inversion. 

Submucous fibroids with partial inversion may not be recognized 
from a simple inversion before operating for the removal of the 
tumor. 

Prolapsus uteri is distinguished from an inversion by the obliter- 
ation of the vaginal fornices, by finding the external os at the bottom 



DIAGNOSIS OF MALPOSITIONS OF THE UTERUS. 



193 



of the protruding mass, and by the absence of a cup-shaped depres- 
sion in the fundus. A sound passed through the cervix will sink 
to the depth of the normal uterine cavity. 



Fig. 93. 




Fig. 94. 




Fig. 93.— Cervical polyp, possible to mistake for an inverted fundus. The differential diag- 
nosis is made by passing a sound into the uterine cavity and by locating the fundus in a 
bimanual examination. 

Fig. 94.— Cervical polyp with atresia of the cervix. A sound cannot be passed into the 
uterus, but the fundus is located within the pelvis by a conjoined examination. 



ANTEVERSION OF THE UTERUS. 



ISTo sharp distinction can be drawn between a physiological and 
a pathological anteversion of the uterus. Within perfectly normal 
limits the long axis of the uterus is turned forward upon an imag- 
inary transverse axis. A permanent exaggeration of this condition 
may be regarded as pathological. 

Etiology. A temporary and physiological anteversion is found 
when the rectum is distended and the bladder empty, and also in 
the early months of pregnancy. 

Chronic metritis is the most common cause of pathological ante- 
version. The increased weight of the uterus causes the body to fall 
forward, the cervix to turn backward. 

Contraction of the uterosacral ligaments from a retro-uterine 

13 



194 SPECIAL DIAGNOSIS. 

cellulitis will draw the cervix backward and tilt the body forward. 
Here retroposition is commonly associated with anteversion. 

More rarely adhesions bind the anterior surface of the uterus to 
the bladder or abdominal wall. 

Any swelling behind the uterus may exert pressure upon the 
uterus in a manner that will produce an anteversion. 

A mural fibroid located in the anterior wall of the uterus may cause 
the uterus to revolve forward by increasing the weight of the body. 

The diagnosis is made by a conjoined examination. The cervix 
points backward, or backward and upward, and the body is palpated 
through the anterior wall of the vagina lying well upon the bladder 
and behind the symphysis. So extreme may the version be that 
the body may press down upon the anterior vault of the vagina, 
forming a rounded swelling not unlike a cystocele in appearance. 
In such a case the external os will be difficult to touch with the 
examining finger. 

When for any reason the position of the uterus cannot be located 
by a conjoined examination, the sound will determine the direction 
of the uterine canal. 

There are no characteristic symptoms. Frequent urination is 
the most constant complaint. Where other symptoms exist they 
are usually caused by complications rather than by the simple 
displacement. 

After locating the uterus in anteversion, the next step is to 
determine the cause of the displacement. 

ANTEFLEXION OF THE UTERUS. 

As with anteversion, so with anteflexion of the uterus ; it is not 
possible to draw a line between the normal and the abnormal posi- 
tion. In anteflexion the uterus is bent forward upon its long axis. 
The cervix is directed downward and forward and the body for- 
ward, thereby forming an angle at the junction of the body and 
cervix. 

In an abdominovaginal examination the body should be engaged 
between the two hands and the angle of flexion felt by the finger 
within the vagina. When the anteflexed uterus lies in retroposi- 
tion, the flexion may be best found by the finger high in the 
rectum feeling the angle upon the posterior surface of the uterus as 
the body bends forward upon the cervix. This examination will 



PLATE XXV. 

Fig. 1. 




Anteversion of the uterus. The cervix points backward to the 
sacrum, the body forward upon the bladder and anterior vaginal 
wall. The long axis of the uterus is straight. 

Fig. 2. 




Anteflexion of the uterus. The uterus is bent forward upon its 
long axis. There is very little alteration from the normal. 



PLATE XXVI. 

Fig. 1. 




Retroversio-flexion of the uterus with adhesions. The body is 
adherent in the eul-de-sae. The long axis of the uterus is bent back- 
ward, and the cervix is directed downward. 

Fig. 2. 



VV-, io^\ 




Incarcerated subperitoneal fibroid on the posterior wall of the uterus. 
The fibroid may be confounded with the body of the uterus. 



DIAGNOSIS OF MALPOSITIONS OF THE UTERUS. 195 

be materially facilitated by an anaesthetic. The sound will be of 
special service when it is otherwise impossible to outline the uterus 
because of tumors and inflammatory exudates encroaching upon it. 
The size, shape, and consistency of the uterus will usually serve to 
distinguish the uterus from all such swellings. 

Having determined the position of the uterus, and before any 
treatment is proposed, it is essential to clearly define the cause of 
the displacement. Is the uterus fixed or free and movable ? If 
free and movable the fault may be a hypoplasia of the uterine wall 
at the point of flexion, and is, in all probability, a congenital defect. 
If the uterus is restricted in its movements, the cause may be a 
congenital or an acquired shortening of the uterosacral ligaments ; 
new formations and exudates lying behind the body of the uterus 
and crowding it forward ; less frequently an increase in the weight 
of the body of the uterus. 

An intramural fibroid lying in the anterior wall of the uterus 
may form an angle with the cervix, which to the examining finger 
resembles an anteflexion. The form and consistency of the tumor, 
together with the passage of the sound, will locate the uterus apart 
from the tumor. (See Plate XXV., Fig. 2.) 

Anteversion and anteflexion are frequently combined. 

The subjective signs of anteflexion of the uterus are frequent 
urination, dysmenorrhoea, and sterility. It is not likely, as is 
generally believed, that dysmenorrhoea is due to obstruction to the 
outflow of the menstrual blood. The angle of flexion can scarcely 
be so acute as to interfere with the flow of blood. The explanation 
probably lies in the accompanying inflammatory lesions in and about 
the uterus and possibly also in spasmodic contractions of the internal 
os. Sterility can probably be accounted for by the accompanying 
inflammatory lesions rather than by the flexion. When the cervix 
points well forward the spermatozoa cannot so readily gain access to 
the cervix as when directed toward the posterior wall of the vagina. 

RETROVERSIO-FLEXION OF THE UTERUS. 

In retroversion the long axis of the uterus revolves backward 
upon an imaginary transverse axis. Such a position is physio- 
logical when the bladder is full and the rectum empty. 

In retroflexion the uterus is bent backward upon its long axis. 
There is no physiological retroflexion of the uterus. 



196 SPECIAL DIAGNOSIS. 

The two positions, retroversion and retroflexion, are caused by 
the same factors. The two are commonly combined, retroflexion 
following retroversion. Because of their intimate association they 
will be discussed together. In virgins and in chronic metritis the 
uterus is seldom flexed, but remains in retroversion rather than in 
retro versio-flexion. 

Etiology. Shultze gives five causes for retro versio-flexion, 
namely : 

1. Failure in development. 

2. Fixation of the portio-vaginalis on the anterior pelvic wall. 

3. Unilateral posterior fixation of the cervix. 

4. Shortening of the posterior or lengthening of the anterior 
uterine wall. 

5. Eelaxation of the supporting uterine ligaments and muscles. 

1. Among the developmental failures contributing to retroversio- 
flexion may be mentioned the proportionately long cervix and short 
vagina. In the presence of such a condition an increase in the 
abdominal tension or a sudden fall would be sufficient cause for a 
retroversio-flexion. 

2. Fixation of the portio-vaginalis upon the anterior pelvic wall 
may be the result of cicatricial contraction of the anterior wall of 
the vagina. Hence it is that retroversio-flexion is frequently 
found in large vesicovaginal fistulas and in stenosis of the vagina. 

3. Unilateral posterior fixation of the cervix occurs in about 6 per 
cent, of all cases of retroversio-flexion (Shultze). The cause is 
retro-uterine cellulitis or peritonitis, more often confined to one 
sacro-uterine ligament. 

4. Shortening of the posterior wall or lengthening of the anterior 
wall of the uterus is a rare finding. 

5. Relaxation of the supporting uterine ligaments and muscles is 
by far the most frequent cause of retroversio-flexion. When 
these supports are weakened the long axis of the uterus first revolves 
backward upon an imaginary transverse axis (retroversion), and 
later, through the force of intra-abdominal pressure, the long axis 
of the uterus is bent upon itself (retroflexion). The stretching and 
tearing of childbirth largely account for the relaxation of the sup- 
porting uterine ligaments and muscles. Retroversio-flexion due to 
violent exertion or to a fall is difficult to establish, though not im- 
possible. The cause of retrodisplacements of the uterus in the 
nullipara is difficult of explanation in the absence of swellings 



DIAGNOSIS OF MALPOSITIONS OF THE UTERUS. 197 

crowding the uterus backward or adhesions pulling it backward. 
Tight lacing and habitual overfilling of the bladder will account 
for a limited number of these cases. Xot a few are congenital, as 
is shown by anatomical dissections of infants. Salin found as many 
nulliparae as multiparas with retroversio-flexion. He estimates the 
frequency of this displacement in all cases at 18 per cent. 

Heredity probably plays no role, though mother and daughters 
are often similarly affected. 

During the puerperium, when the uterus is large and soft, the 
ligaments relaxed, and the patient lying on her back, all the con- 
ditions favoring retroversion are present. This retroversion may 
go on to the development of a retroflexion through the influence of 
intra-abdominal pressure. Rising too early from childbed favors 
malpositions, as well as does lying too long in the dorsal position. 
It is for the purpose of avoiding such malpositions that the patient 
is instructed to lie in bed until the uterus and ligaments are well 
contracted and retracted. It is obvious that the patient should not 
lie constantly in the dorsal position, but should from time to time 
assume the knee-chest position, or at least lie upon the side or face. 

As to the frequency of retrodeviations of the uterus, the statistics 
of Winckel, Lohlen, and Sanger show an average of 17.74 per cent, 
of all gynecological cases (Reed). 

Anatomical Diagnosis. When the cervix is crowded forward 
the anterior vaginal wall is relaxed, while the posterior wall is taut 
In retroversion the cervix points forward or forward and upward, 
sometimes lying above the level of the symphysis. In retroflexion 
the cervix is directed downward and backward. When the body 
of the uterus lies in the hollow of the sacrum, the cervix must 
necessarily lie well forward to the symphysis. If, as is often found, 
retroversio-flexion is associated with descensus uteri, the cervix 
may be elongated. If a bilateral laceration of the cervix is present 
the vaginal walls will draw the lips of the cervix wide apart, expos- 
ing the mucous membrane of the cervical canal. 

In retroversion the body of the uterus approaches the promon- 
tory, and may be found low in the pouch of Douglas. There is no 
angle of flexion between the body and cervix. The cervix and 
body lie in a straight line. In retroflexion the body may form an 
acute angle with the cervix. Often the uterus in retroversio-flexion 
inclines to the left or right, and in extreme cases is almost invariably 
more or less prolapsed. 



198 SPECIAL DIAGNOSIS. 

(Edema and passive congestion, leading to hyperplasia of the 
endometrium and myometrium, are the almost inevitable results of 
the displacement. We, therefore, find endometritis and metritis 
associated with long-standing retroversio-flexion. Not seldom do 
diffuse peritoneal adhesions bind the uterus, tubes, ovaries, and 
bowel together. The tubes and ovaries lie at a low level and suffer 
congestion and hyperplastic changes, leading to catarrhal salpingitis 
and chronic ovaritis. 

The bladder may be directly pressed upon by the cervix, causing 
frequent urination. In the retroflexed gravid uterus there may be 
retention of urine. 

The rectum is coqi pressed, and may be obstructed by the body of 
the uterus. 

Clinical Diagnosis. . The great number of cases of retroversio- 
flexion in which no symptoms are present speaks for the unreliability 
of subjective signs. E. Shroeder reports 411 cases examined, in 
which 188 (28.7 per cent.) had retroversio-flexion of the uterus, 
and of this number 25 per cent, were free from symptoms. He 
reasons that uncomplicated retrodisplacements of the uterus cause 
no symptoms ; that those so frequently ascribed to such displace- 
ments are due to complicating lesions. Yet how often do we find 
extensive adhesions fixing the uterus in malpositions without caus- 
ing either local or general disturbances ? On the other hand, the 
disappearance of local disturbances immediately upon the correction 
of a non-complicated displacement cannot be wholly explained on 
the ground of suggestive treatment. 

1. Menstrual irregularities are common, and usually take the form 
of an increase in the menstrual flow. This is explained by the 
passive congestion of the uterus. Extreme anaemia may result 
from the loss of menstrual blood. The menopause may be delayed 
because of the passive congestion. During pregnancy and the period 
of lactation occasional hemorrhage may be similarly accounted for. 

2. The habit of abortion is in many instances explained by the 
uterine congestion. 

3. Leucorrhcea in the form of a hypersecretion of the glands of 
the uterus is almost invariably present, and is caused by passive 
congestion of the uterus. 

The congested uterus is a favorable nidus for micro-organisms, 
and so it happens that the glandular secretion is often mixed with 
pus and micro-organisms. 



DIAGNOSIS OF MALPOSITIONS OF THE UTERUS. 199 

4. Dysmenorrhea of the so-called congestive type is seldom 
absent. It is not probable that the menstrual flow is obstructed 
at the point of flexion. The occurrence of pain is probably ex- 
plained by the addition of the menstrual congestion to the already 
congested uterus. 

5. Sterility is a not uncommon result of retroversio-flexion of the 
uterus. The incapacity for childbearing should be credited not so 
much (if at all) to the flexion of the uterus as to the inaccessibility 
of the cervix to spermatozoa when crowded forward and upward, 
to endometritis, and to complicating lesions in the adnexa and 
perimetrium. 

6. Disturbances of the functions of the bladder and rectum are 
accounted for by direct pressure. 

7. Pain in the pelvis referred to the groin, thighs, and back is 
the most constant of the subjective signs, but cannot be regarded 
as of great importance from a diagnostic standpoint, because pain 
is not an invariable symptom and does not differ from that caused 
by other lesions of the pelvic viscera. Backache is a common 
complaint and is referred to the coccyx (coccygodynia), to the lumbar 
region, or to the area between the scapula? ; rarely to the cervical 
region. The absence of pain in many extreme retrodisplacements 
of the uterus suggests a doubt that the displaced uterus per se is 
the cause of the pain. Certainly the accompanying lesions, such 
as ovaritis, salpingitis, and perimetritis, account in large measure 
for the pain. Pressure upon the sacral plexus of nerves is the 
explanation of the pain referred to the thighs, and since the uterus 
is rarely found in the median line these referred pains in the lower 
extremities are for the most part unilateral. 

8. Reflex symptoms, such as headache, neuralgia, dyspepsia, hys- 
teria, and neurasthenia, are often attributed to the displacement, 
but it seems impossible to demonstrate such to be a fact with any 
degree of positiveness. 

It is clear that a diagnosis cannot be based upon the subjective 
signs. Too many cases exist in their absence, and the complaints 
of the patient are those found in almost any of the lesions of the 
pelvis. A physical examination is therefore required to establish a 
diagnosis. A diagnosis includes not only the location of the uterus, 
but also the condition of the adnexse and neighboring structures. 
Here, as in the diagnosis of all displacements of the uterus, it is 
first necessary to locate the uterus, and, second, to determine the 



200 SPECIAL DIAGNOSIS. 

underlying cause of the displacement, and the existence of compli- 
cating lesions within the pelvis and abdominal cavity. 

In making a bimanual examination the position of the vaginal 
portion of the cervix may be an indication of the position of the 
uterine body. For example, if the cervix lies in its normal position 
pointing downward and backward toward the second sacral vertebra, 
the body must lie in the normal position or retroflexed ; it would 
be impossible for a retroversion to exist with the cervix pointing 
downward and backward. If the cervix lies in front of its normal 
position and pointing directly downward, one of two positions is 
present, a retroflexion or an anteposition. It is sometimes possible 
to recognize a retroflexion in a simple vaginal palpation by feeling 
the angle of flexion through the posterior fornix. Where condi- 
tions are not favorable a positive diagnosis of the position of the 
uterus can only be made by a conjoined examination under anaes- 
thesia. A recto-abdominal or recto-vagino-abdominal examination 
afford better means of palpating the uterus when lying far back 
against the rectum. 

The use of the sound should be restricted, but it is occasionally 
called into service when a bimanual examination will not suffice. 

Is the Uterus Fixed or Movable f First of all we must have 
clearly in mind what constitutes normal mobility of the uterus. It 
is not enough that the uterus should permit the usual excursions 
when manipulated, but it must return to its normal position when 
pressed out of place. Failing to do so constitutes a pathological 
condition. 

The fixity of the uterus is determined by the effort to replace it. 
Sensitiveness and thickness of the abdominal wall may render an 
anaesthetic necessary. 

The technic of replacing a uterus in retroversio-flexion is briefly 
outlined as follows : 

The bladder and rectum are empty. The patient lies in the 
lithotomy position. One, and where possible without pain, two 
fingers are inserted into the posterior vaginal fornix, and moderate, 
steady pressure is made upon the uterine body in an upward and 
forward direction. The hand over the abdomen presses steadily in 
the effort to pass over and behind the fundus, as it is forced upward 
and forward by the fingers in the vagina. Sometimes the body will 
rotate forward by the finger pressing backward upon the cervix. 
With the middle finger in the rectum, it is possible to exercise more 



DIAGNOSIS OF MALPOSITIONS OF THE UTERUS. 201 

direct pressure upon the body of the uterus in extreme retroflexion. 
Traction upon the cervix by a tenaculum will bring the uterus 
more within reach of the ringers in the vagina and rectum. An 
anaesthetic is usually advisable. Formerly, in reposition of the 
uterus, a sound was advised, but the dangers of perforation are too 
great to justify its general use. Certain it is that the sound should 
not be used where the uterus is fixed. In replacing the uterus force 
must not be used for fear of tearing existing adhesions, causing 
hemorrhage, and injuring adherent viscera. 

Having determined the position of the uterus and the fact that 
it is not replaceable, it next becomes necessary to determine the 
cause of the inhibition. As possible causes may be mentioned 
adhesions and pelvic exudates, inflammatory contractions of the 
ligaments, and pelvic tumors. Peritonitic adhesions (peritonitis) 
for the most part arise from extension of infection through the 
tubes and are most often found about the tubes and ovaries. Since 
infected tubes commonly lie in the cul-de-sac of Douglas, the sur- 
rounding adhesions may bind the uterus to the rectum in retrover- 
sion or retroflexion. Peritoneal adhesions are recognized by their 
location on surfaces covered with peritoneum and by the ease with 
which they may be broken up as compared with parametritic adhe- 
sions. 

Parametritic adhesions correspond in location to cellular tissue of 
the pelvis which is found between the layers of the broad ligament, 
underneath the pouch of Douglas, and to a limited extent in front 
of the uterus beneath the vesico-uterine fold of peritoneum. 

Retroversio-flexion may be brought about by adhesions in the 
cellular tissue of the vesico-uterine space drawing the cervix forward 
and rotating the body backward — this, however, is quite unusual. 

Retro-uterine parametritis, when involving only the supravaginal 
portion of the cervix, tends to produce an anteversion by drawing 
the cervix backward and rotating the body forward. In extreme 
cases the uterorectal fold of peritoneum may be crowded upward 
and permit the parametritic adhesions to adhere high up upon the 
posterior surface of the uterus, and by traction upon the body a 
retroversion is caused. Parametritic adhesions are thicker and 
firmer than they are in parametritis. They are found on a lower 
level, are more accessible through the vagina, and are located where 
the cellular tissue of the pelvis is found. 

Pregnancy in a retroflexed uterus may prove a serious condition. 



202 SPECIAL DIAGNOSIS. 

No special difficulty is experienced in the first twojnonths, but in 
the third and fourth months the uterus, no longer able to accom- 
modate itself to the small pelvis, is prevented from rising into the 
abdominal cavity. As a result pregnancy will be interrupted, or 
pressure symptoms will become increasingly severe and demand 
operative interference. On bimanual examination the large, soft, 
and elastic uterus may be found to bulge into the posterior vaginal 
fornix even to the introitus. The cervix is forced high behind the 
symphysis, and is directed forward or forward and downward. 
The soft cervix and softer lower uterine segment may be felt to 
connect at an angle with the large, rounded, soft, and elastic body 
of the uterus. Because of the great softening the uterine body 
may appear detached from the cervix, and in case the cervix is 
hypertrophied it may be mistaken for the entire uterus and the body 
may be thought to be a new-growth. 

Differential Diagnosis. Eetroversio-flexion is most often con- 
founded with retroposition. In the latter the cervix lies in the 
posterior segment of the pelvis, while in retro versio-flexion it lies 
anterior to the normal position. In both conditions the body of 
the uterus lies far back in the pelvis, but in the latter the long axis 
of the uterus is no longer in the normal line of direction. 

Anteflexion may be mistaken for retroversion. The cervix 
points in the same direction — forward and downward — and the 
body may be small and therefore overlooked or mistaken for the 
supravaginal portion of the cervix. If on bimanual examination 
the body of the uterus cannot be located a sound may be passed. 

A retro-uterine subperitoneal or interstitial fibroid may form an 
angle with the cervix that can be mistaken for the body flexed upon 
the cervix. The body of the uterus is recognized by its size, form, 
consistency, and direct relation to the cervix. Such a fibroid should 
present a circumscribed area of firmer consistency and produce an 
irregularity in the uterus. Where the bimanual examination will 
not suffice for a diagnosis, the uterine sound may be used. 

Swellings of the tubes and ovaries lying behind the uterus, retro- 
uterine hsematoma and hematocele, and parametritic exudates are 
all to be differentiated from retroversio-flexion by a consideration 
of the clinical history and by finding a mass behind the uterus that 
differs in size, form, and consistency from the uterus, and which, 
by the use of the sound, is found to be separate from the uterus. 
For further discussion, see respective chapters on these subjects. 



DIAGNOSIS OF MALPOSITIONS OF THE UTERUS. 203 



HERNIA OF THE UTERUS (HYSTEROCELE). 

Hernia of the uterus is of rare occurrence. The rupture usually 
occurs through the inguinal canal, less often through the crural 
ring. The only two recorded cases of crural hernia are those of 
Bowen and Duges. Fifteen cases of inguinal hernia of the uterus 
were collected by Kustner ; of these, eight were pregnant. The 
explanation of the development of the hernia is usually given as 
traction made upon the uterus by adhesions binding the hernial sac 
to the uterus and drawing the uterus within the sac. There is 
generally some associated anomaly in development. 

The diagnosis is made by palpation and by an exploratory 
incision. 

Hernia of the uterus through the linea alba may follow ventro- 
suspension. Plate IX. represents a hernia of a uterus in the 
fourth month of pregnancy. 



CHAPTEE XXII. 

THE DIAGNOSIS OF DISEASES OF THE VULVA. 

For a detailed description of the anatomy of the external genital 
organs, the reader is referred to text-books on gynecology and 
human anatomy. 

ANOMALIES IN THE DEVELOPMENT OF THE VULVA. 

Absence of the Vulva. This condition is very rare, and is, as 
a rule, associated with a congenital absence of the internal organs 
of generation. Absence of one or more of the component struc- 
tures of the vulva is not of such rare occurrence, and may be found 
associated with well-formed internal organs of generation. 

Double vulva is an extremely rare condition. The clitoris may 
be absent, bifid, small, or large. 

Atresia of the vulva may be found associated with a communica- 
tion between the rectum, bladder, and genital canal. The foetus 
is rarely viable, but may be found in mature years. 

The infantile type of the vulva may be maintained after puberty. 

The entire vulva, or one or more of the component parts, may 
fail to mature to the full sexual type. Cretins and dwarfs mostly 
retain the infantile type. The vulva may mature at the time of 
puberty, and subsequently undergo atrophic changes involving part 
or all of the vulva. Causes for such atrophy are found in the 
wasting diseases, in certain nervous disorders, such as epilepsy, 
and after removal of the ovaries. A physiological atrophy occurs 
after the menopause. 

Hypertrophy of the vulva rarely involves all structures composing 
the vulva. The clitoris is most commonly affected, it sometimes 
assumes the proportions of the penis, and has been mistaken for it. 

Congenital Fissures of the Vulva, (a) Epispadias is caused by 
failure of closure on the part of the anterior abdominal wall, together 
with a dehiscence of the anterior wall of the alantois. The alantois 
thus communicates with the outer world. 



THE DIAGNOSIS OF DISEASES OF THE VULVA. 



205 



(b) Hypospadias is formed by a persistence of the urogenital 
sinus. The urethra and vagina open high up in the vestibular 
canal. The perineum is well-developed. The urethra may be 



Fig. 95. 



MONS VENERIS 







f 



Vulva of a virgin. The labia have been widely separated. (Testdt.) 

absent and the bladder communicate directly with the vagina. 
Here the urogenital sinus has disappeared, and the bladder and 
vagina open directly into the vestibular canal. 



HERMAPHRODITISM. 

True hermaphroditism has not as yet been proven to have an 
existence. Xagle says that it is not likely that the ovaries and 
testicles can coexist, and without their coexistence true hermaphro- 
ditism is impossible. 

In pseudohermaphroditism the vulva presents the appearance of 
the male genital organs. The hypertrophied clitoris resembles the 



206 SPECIAL DIAGNOSIS. 

penis ; the coalescence of the labia majora and minora hiding the 
vagina suggests the scrotum. One or both ovaries may descend 
into the coalesced labia and be mistaken for the testicles within 
the scrotum. 

On the other hand, there are males in whom the external genitals 
resemble those of the female. The testicles may either be absent 
or not descended ; there may be a small penis, no larger than the 
clitoris, and the scrotum may present a median depression. Where 
the urogenital sinus persists, the male type may be closely simulated. 
In such cases the urethra opens at the base of a very small penis, 
and running from the urethra to the base of the penis is a frsenum. 
Rudimentary labia and hymen lie below the urethra, and above 
this a vagina of variable extent. The uterus and tubes are present, 
but are often quite rudimentary. The general development of the 
pelvis, larynx, and breasts suggests the feminine type. Such indi- 
viduals commonly pass for females, and the true condition may not 
be recognized even after marriage. 

VULVITIS. 

Etiology. In seventy examinations of the secretions found in 
the vestibule, Menge found the streptococcus three times, the 
staphylococcus twice, and the bacterium coli communis once; in 
all cases saprophytic bacteria were found. Menge accounted for 
the infrequency of pathogenic bacteria on the ground of bactericidal 
action of the vaginal secretion. The tubercle bacillus has been 
demonstrated in the secretions of the vulva by Menge, Chiari, 
Dechamps, and Demure. Diphtheritic vulvitis has been identified 
many times by the finding of the specific organism. 

It has been estimated that 75 per cent, of the cases of vulvitis 
are caused by gonorrhoea. The leptothrix and oidium have been 
demonstrated by Wenkel. 

In addition to the above-named essential factors, may be men- 
tioned certain exciting causes, such as excessive sexual intercourse, 
masturbation, uncleanly habits, irritating urine, and vaginal secre- 
tions. 

The following varieties are recognized : 

Vulvitis furunculosa, in which multiple small abscesses are found 
upon the labia majora, less frequently upon other portions of the 
vulva. These abscesses are usually found in the sebaceous and 



THE DIAGNOSIS OF DISEASES OF THE VULVA. 



207 



sweat glands. Of all the glands of the vulva, the Bartholinean 
glands are most commonly infected, and gonorrhoea is the cause in 
a great majority of the cases. As a rule, the glands are not exten- 
sively involved. The mouths alone of the glands may be involved, 
giving rise to the so-called " maculae gonorrhoeica " of Sanger. 
Gebhard affirms that when suppuration occurs in the gland there 
is always a mixed infection of the gonococcus and staphylococcus. 
It is very unusual to observe Bartholinitis in infants. The size 
which these infected glands may attain is from that of a split pea 
to a man's fist. 



Fig 



Fig. 97. 




Enlargement of the vulvovaginal gland by 
cyst or abscess. (Schaffer.) 



Right inguinal hernia simulating vulvo- 
vaginal cyst or abscess. Eversion of anterior 
and posterior vaginal walls. (Schaffer.) 



The infected Bartholinean gland is located in the labia majora ; 
is round or oval, firm or fluctuating, and may or may not be tender 
to pressure. 

It is to be differentiated from hernia into the labium (Figs. 
96 and 97). The latter is not tender to pressure, is elongated, 
tympanitic on percussion, and may be made to disappear by taxis. 
When reduction of the hernia is impossible, and when strangu- 
lation and gangrene of the gut have occurred, the usual symptoms 
of intestinal obstruction will suggest the probable nature of the 
swelling. Evidence of gonorrhoeal- infection elsewhere in the 
genito-urinary tract will be suggestive. 



208 SPECIAL DIAGNOSIS. 

Puerperal vulvitis occurs as a result of an irritating lochial dis- 
charge. A diffuse erythema and ulceration may arise. The ulcers 
are usually superficial, with a gray or brownish colored base and an 
infiltrated margin. A false membrane may cover the ulcerated 
surface, suggesting in appearance a diphtheritic ulcer. The organ- 
ism commonly found in these ulcers is the streptococcus. Very 
rarely the Klebs-LoefHer bacillus is obtained. 

Erysipelatous vulvitis may arise from a primary infection of the 
vulva by the streptococcus of erysipelas. It is frequently observed 
in the newborn. In a case of the author's it spread from the vulva 
to the vagina, uterus, tubes, and peritoneum. 

Tuberculous vulvitis is a rare lesion. Irregular ulcerations are 
found at any point in the external genitals. These ulcers have a 
ragged, undermined margin, with an irregular base covered with 
pus and studded with grayish tubercles. Fistula? may lead to the 
bowel. Extensive cicatrization, causing deformity of the vulva, 
may follow the ulceration. The tubercle bacillus is difficult of 
demonstration in the secretion. The outpour from the involved 
structures will show giant cells and tubercles, more rarely the 
tubercle bacillus. 

Syphilitic vulvitis occurs in the primary, secondary, or tertiary 
stages. In the primary stage the chancre may be found at any 
point on the vulva. The lesion varies in proportion to the asso- 
ciated oedema and cellular infiltration, the greatest swelling occur- 
ring in the labia majora, where the cellular tissue is loosest and 
most abundant. In the secondary stage the vulva is often covered 
with condylomata, which early ulcerate and are covered with a 
slimy secretion of a highly infectious nature. In the tertiary stage 
gummata are rarely found. 

The so-called soft chancre (ulcus molle) has its favorite seat in 
the frenulum and labia minora. The ulcer formed from the soft 
chancre is round, with a sharp border and a smooth base covered 
with pus. In the neighborhood of the ulcer the vessels are mark- 
edly dilated. 

CIRCULATORY DISTURBANCES OF THE VULVA. 

During pregnancy, and in the case of pelvic tumors and inflam- 
matory exudates, the veins of the vulva may be widely distended. 
Thrombosis of the veins and calcareous deposits in the coagula (vein 
stones) are not of infrequent occurrence. 



PLATE XXVII. 




f 



Vulva of non-parous woman, closed. ( Jewett. ) 






PLATE XXVIII. 




1 



Vulva of non-parous woman, open, hymen intact. 

( Jewett. ) 



PLATE XXIX. 




Vulva of parous woman, closed. ( Jewett. ) 



PLATE XXX. 




; 



Vulva of parous woman, open. (Jewett. 



THE DIAGNOSIS OF DISEASES OF THE VULVA. 209 

Angioma vulvae is a term applied to polypoid protuberances formed 
from dilated veins and blood extravasations. The mass is of a 
bluish color. Rupture of the veins may result seriously. 

Hematoma of the vulva may arise from rupture of the veins 
during labor or from direct injury. Such accumulations of blood 
may attain the size of a man's head. While suppuration of the 
blood clot may occur, gradual absorption is the rule. 

(Edema of the vulva may arise from an obstruction to the general 
circulation in diseases of the heart, kidney, liver, etc., but it is 
more often the result of local interference from pressure of the 
pregnant uterus, pelvic tumors, and exudates. The swelling may 
be bilateral or confined to one side, and may be as large as a child's 
head. 

Gangrene of the vulva has been observed in weakly children, in 
the course of septic febrile diseases, and following pregnancy. 

Hypertrophy of the Vulva. The clitoris and labia majora may 
undergo simple hypertrophy, either as a congenital or as an 
acquired lesion. The increase in size may or may not be inflamma- 
tory in origin. Of hypertrophic lesions due to inflammation the 
most common are the condylomata acuminata, which are almost 
invariably of gonorrheal origin. 

The latter growth is particularly rapid during pregnancy and is 
said to be caused by the irritating vaginal discharge. In the early 
stage of development these warty outgrowths are pale red or gray. 
Later the papillary projections become confluent and may assume 
the proportions of a man's fist. Occasionally the growth is pedun- 
culated. They are found distributed over part or all of the vulva, 
vagina, and the neighboring skin surface of the mons veneris, groin, 
buttocks, and perineum. The lesion is essentially an overgrowth 
of the papilla?. The greater part of the growth is due to. an increase 
in the epithelial covering of the papillae. In general appearance 
such a growth is not unlike a cauliflower carcinoma. The distinc- 
tion is made by the frequent occurrence of the growth during preg- 
nancy ; by the history of gonorrhoea, and the presence of gonococci 
in the secretions, together with other evidences of gonorrhoea ; by 
the age of the individual, and, finally and conclusively, by the 
microscopic examination of an excised piece in which there is an 
absence of epithelium invading the underlying connective tissue. 

Elephantiasis. In the early stage of development the growth is 
not unlike simple hypertrophy, but as it progresses it tends to 

14 



I 



210 



SPECIAL DIAGNOSIS. 



become more and more pedunculated and may extend to the knees, 
weighing several pounds. When the surface is smooth it is known 
as elephantiasis glabra ; when nodular, elephantiasis tuberculosa, and 
when covered with warty excrescences, elephantiasis condylomata. 
The surface may be more or less ulcerated. 



Fig. 98. 




Elephantiasis of the vulva. (Bonnet and Pettit.) 

The point of origin may be the labia majora, labia minora, mons 
veneris, or clitoris. It is unusual for the growth to arise simul- 
taneously from two or more of these surfaces. 



THE DIAGNOSIS OF DISEASES OF THE VULVA. 211 

The greater portion of the growth is of connective tissue, with 
cedematous infiltration of the connective tissue spaces. There is 
a scant blood supply to these growths. 

The essential cause is as yet unknown. Elephantiasis sometimes 
arises from the base of old ulcers and suppurating buboes. Stenosis 
or occlusion of the lymph channels is undoubtedly an underlying 
factor, but the cause of obstruction to the lymph channel is unknown. 

The patient consults the physician because of the weight of the 
growth and its interference with walking and coition. 

The diagnosis will involve little difficulty. It is distinguished 
from carcinoma by the absence of friability, the slow growth, and, 
finally, by a microscopic section showing an absence of epithelial 
invasion of the connective tissue and the presence of connective 
tissue hyperplasia. There are no constitutional effects. 

Urethral caruncle is a localized inflammatory hypertrophy of the 
urethral mucosa located near the external meatus. These elevations 
are usually single, rarely multiple. They attain the size of a hazel- 
nut, are red or bluish-red in color, sensitive to pressure, soft, and 
attached by a broad base or pedicle. The surface is smooth or 
folded, and bleeds but slightly on handling. 

The growth consists in large part of connective tissue infiltrated 
with small round cells, with here and there blood extravasations. 
The surface is commonly covered with several layers of the flat 
epithelium of the vestibule. Tubular glands invade the structure, 
and are lined with epithelium varying in form from flat to columnar. 
Neuberger believes gonorrhoea to be an underlying cause. The 
lesion is frequent in old age. Urination and sexual intercourse are 
painful, because of the great sensitiveness of the caruncles. 

ATROPHY OF THE VULVA (Kraurosis Vulvae). 

After the menopause there occurs a physiological atrophy of the 
vulva, in which the labia majora lose their plumpness, the labia 
minora diminish in size and may wholly disappear, the clitoris is 
shortened, the mucous membrane becomes dry and pale, and the 
vulvar orifice is narrowed. 

Kraurosis vulvae is a term applied to a specific form of atrophy of 
the vulva, the cause of which is unknown. The extent of the 
atrophy may be greater than the atrophy of old age. The labia 
majora are flat and flaccid, while the mucosa may be so friable as 



212 



SPECIAL DIAGNOSIS. 



to be injured by the examining finger. The labia minora and 
clitoris may wholly disappear. In addition to the dryness of the 
surface there is extreme sensitiveness. Dyspareunia is a common 



Fig. 99. 




Kraurosis vulvae. Clitoris and labia minora completely atrophied ; the labia majora flattened 
and wrinkled. (Gebhard.) 



Fig. 100. 




ft' , ^' j\- *>■■$ > J f^ Jfa V- * 



Kraurosis vulvae. Marked hornification of tbe corium, with round-cell infiltration; papillae 

are absent. (Gebhard ) 



THE DIAGNOSIS OF DISEASES OF THE VULVA. 213 

complaint, and when associated with itching and a sense of dryness 
in the vulva the possibility of kraurosis is to be borne in mind. 
Kraurosis occurs chiefly in women of advanced age ; in women who 
have borne children and have become sterile ; in the married, and 
in the widow. The lesion sometimes follows removal of the 
ovaries. That it is due to syphilis and gonorrhoea is quite improb- 
able. 

The lesion is probably of inflammatory origin. The glandular 
structures of the affected area disappear ; the papillae are poorly 
developed, and the corium is atrophied. 

NEW FORMATIONS OF THE VULVA. 

Benign tumors of the vulva are of rare occurrence. 

Fibromata arise from the subcutaneous connective tissue of the 
labia majora and minora, rarely from the clitoris. They are slow 
in their growth, firm, round, and sharply circumscribed. The 
overlying skin is not adherent to the tumor. They are known to 
grow to the size of the patient's head and hang by a pedicle as low 
as the knees. The microscope shows the tumor to be composed of 
connective tissue intermixed with a limited amount of smooth 
muscle fibre. Cystic degeneration and calcareous deposits have 
been described. 

Lipoma arises from the subcutaneous fat of the mons veneris 
and labia minora. They are not so frequently found as are fibromata. 
They are usually circumscribed, soft in consistency, sometimes 
apparently fluctuating, and are attached either by a broad base or 
pedicle. I am able to find only twenty-two cases of lipoma of 
the vulva in the literature. They are found anywhere from the 
fifth month of infancy to the fifty-first year. 

Enchondroma has not been demonstrated beyond doubt. 

Neuroma have been described as sensitive papillae or warts, 
though the descriptions leave some doubt as to their identity. 

Peckham described a cyst of the clitoris weighing 60 gins., and 
filled with a chocolate-colored fluid. 

Sebaceous eysts are found in the labia, the base of the prepuce, 
and at the base of the hymen. They appear in the form of small, 
yellowish, sem transparent elevations filled with sebaceous material. 
Small, soft- walled cysts lying at the free margin of the hymen may 
be regarded as lymph cysts. 



211 SPECIAL DIAGNOSIS. 

Dermoid cyst of the vulva is of rare occurrence. 
Vulvar cysts have little clinical significance. An accompanying 
pruritus may disclose their presence. 

CANCER OF THE VULVA. 

The vulva is strangely exempt from infection and malignant 
degeneration. In 1147 cancers of the female genitalia Schwarz 
found 30 to be primary in the vulva. Wenkel tabulated the 
report of 54 cases, in which he found 6 before the age of forty, 16 
between forty and fifty, 20 between fifty and sixty, and 20 over 
sixty years of age. 

The site of predilection is the outer skin surface of the labia 
majora ; less frequent points of invasion are the frsenum, clitoris, 
Bartholinean glands, anterior and posterior commissure, and urethral 
opening. The labia minora are seldom a primary site. (See Plate 
XXXI.) 

The lesion is characterized by superficial infiltration, by ulcera- 
tion, and by early involvement of the inguinal glands. The growth 
may be diffused or circumscribed. The circumscribed growths 
rarely fail to rise above the level of the skin surface. They are 
commonly round or oval, the surface smooth, nodular, or papillary. 
They may grow to the size of a man's fist. At first firm in con- 
sistency, sooner or later they disintegrate and form ulcers more or 
less superficial. The diffuse form may not be evident to the naked 
eye, and is recognized by its rigid, firm feel. Superficial ulceration 
is usually not long in appearing. There is nothing unusual in the 
appearance of the ulcer, the base is uneven, bleeding freely to the 
touch, and covered with a purulent, foul-smelling secretion ; the 
margins of the ulcer are irregular, hard, and elevated. In ad- 
vanced cases the ulceration may extend to deep crater-like excava- 
tions, with markedly infiltrated borders. 

Schwarz found the inguinal glands infiltrated with cancer cells 
eleven times in twenty-three cases. The rate of growth is often 
slow. The direction to which the growth extends varies. Most 
commonly the extension is to the vagina and from the vagina 
to the rectum, bladder, and pelvic connective tissue. In not a 
small percentage of cases the opposite labium is invaded (contact 
metastasis). 

The microscopic characters of vulvar carcinoma differ somewhat 



PLATE XXXI. 




v8p^-HPBI;'"i^!EKffl^^ ; Whittle 



Cancer of the Vulva. 

Irregular columns of epithelium project from the surface 
into the connective tissue. Isolated cancer nests and pearls are 
distributed through the connective tissue. There is a round-cell 
infiltration throughout and hyaline degeneration of the pearls. 



THE DIAGNOSIS OF DISEASES OF THE VULVA. 215 

from those of cancer of the vagina and cervix. There is an 
unusual tendency on the part of the epithelial projections to branch ; 
cancer pearls are said to be relatively rare, although in two speci- 
mens, one removed by Dr. Reuben Peterson, the other by Dr. J. 
Clarence Webster, I found an unusual number of cancer pearls. 
The extension of the cancer cells along the lymphatics gives the 
appearance of veins of marble. Cancer of the glands of Bartholin 
is rare. The gland may assume the size of a man's fist, become 
hard and nodular, with a movable, normal appearing overlying 
skin. The diagnosis without the aid of the microscope may be 
impossible. The lesions to be considered in making a diagnosis are 
the benign new formations (lipoma, fibroma) with ulcerated surface, 
ulcus rodens, tuberculosis, syphilis, and elephantiasis. In making 
the diagnosis we rely upon the age of the individual, the general 
effect upon the system, early and superficial ulceration, involvement 
of the inguinal glands, and above all upon the microscopic exam- 
ination of an excised piece of the tumor. The prognosis is relatively 
good. Schwarz saw ten recoveries in twenty-three cases. 

SARCOMA OF THE VULVA. 

This is a very rare lesion. Hunter Robb has described a myxo- 
sarcoma of the clitoris. Melanotic sarcoma of the vulva is an 
intensely malignant growth. Bailley reported a melanosarcoma in 
a woman, aged seventy-two years. 

Recurrence is almost certain. Mueller removed from the 
labium minor a melanosarcoma as large as a walnut. There was 
no recurrence until the end of three years. Fisher reports a 
recovery in a woman, aged fifty-six years, from whom a melano- 
sarcoma the size of a walnut was removed from the labium major. 

CYSTS OF THE VULVA. 

Cysts of the Bartholinean gland are by far the most frequent of 
the cysts of the vulva. They are not to be regarded as new forma- 
tion, but rather as retention cysts. Gonorrhoea is the usual exciting 
cause, and hence they are inflammatory in origin. A diagnosis of 
gonorrhoeal infection can be made to a moral certainty from the 
presence of a Bartholinean cyst. Both glands are commonly 
involved, but the lesion is seldom equally advanced on the two 



216 SPECIAL DIAGNOSIS. 

sides. In the early stage of infection the openings of the glands 
are reddened, and it may be possible to express pus from the gland. 
As the infection extends into the glands they become swollen and 
tender, and if the outlet of the gland is occluded a retention cyst is 
formed. A chronically inflamed cyst may lie quiescent for an 
indefinite period, when through the influence of some mechanical 
insult or secondary infection an acute exacerbation occurs. As the 
gland distends the deep connective tissue is invaded. The infection 
may extend beyond the gland to the loose connective tissue between 
the rectum and vagina, and vagina and urethra. 

The cyst wall is of fibrous tissue lined within by compressed 
epithelium. The wall is usually thin. The contents of the cyst 
are mostly of a thin, serous character, sometimes colloid, purulent, 
or of a dark red color from admixture with blood. In the contents 
may be found blood corpuscles, blood pigment, cholesterin, pus 
cells, leucocytes, epithelium, micro-organisms, and detritis. Veit 
reports three cases in virgins with an intact hymen, the probable 
result of a vulvovaginitis. 

Retention cysts of the glands of Bartholin may be unnoticed by 
the patient or discovered accidentally. When there is an inflam- 
matory reaction in and about the gland pain may be intense. 

It is scarcely possible to confuse cysts of the glands of Bartholin 
with any other lesion. Inguinal hernia and cysts of the round 
ligament lie at a higher level and can be traced to the inguinal 
canal. Solid tumors of the labia majora may be excluded by an 
exploratory puncture or incision and by the inflammatory character 
of the growth. 

Cysts of the labia minora are seldom reported. Agnes Bloom, 
in reporting two cases, gives the following classification : 

1. Cysts arising from the normal structures of the labia minora 
(idiopathic). 

2. Cysts arising from pathological conditions of the labia minora. 

3. Cysts arising from Gartner's ducts. While they are commonly 
quite small, they have been known to grow to the size of an orange. 
They are single or multiple, unilocular or multilocular. The con- 
tents vary, being serous, mucous, or purulent. 



THE DIAGNOSIS OF DISEASES OF THE VULVA. 217 



ULCERS OF THE VULVA. 

Rodent Ulcer. Virchow was the first to describe this lesion. 
The ulcers present elevated, soft, oedeinatous margins ; are very 
slow to heal, and tend to form fistulous communications with the 
vagina and rectum. When the ulcers invade the urethra strictures 
and fistula? may follow. The ulcers grow to the size of a silver 
dollar. There is nothing characteristic in the microscopic findings. 
Giant cells suggestive of tuberculosis have been demonstrated. 

The cause is unknown. That they bear no relation to tubercu- 
losis and syphilis has been conclusively demonstrated. Koch is of 
the opinion that these ulcers arise from lymph stasis following sup- 
puration and cicatricial contraction of the inguinal glands. 

The diagnosis presents many difficulties. The lesion is often 
found in combination with elephantiasis, and by many is considered 
a part of this affection. 

Tuberculous ulcers are distinguished by the presence of the 
tubercle bacillus. Carcinomatous ulcers are not easy to exclude. 
The microscopic examination is essential to a positive diagnosis. 

Syphilitic ulcers are recognized by the history of infection, by the 
general evidence of syphilis which follows, and by the effect of 
treatment. The accompanying elephantiasis is suggestive of ulcus 
rodens. 

PRURITUS VULV.E. 

Pruritus vulvae is a term applied to an itching of the vulva 
accompanied by swelling of the parts and nervous irritability. 

The most frequent area involved is the clitoris ; next in order of 
frequency are the labia, vestibule, mons veneris, perineum, and anus. 

In nearly every instance the lesion is symptomatic, but there is 
a small proportion of cases in which it appears to be idiopathic. 
As a symptomatic lesion the underlying causes are largely attrib- 
utable to mechanical and infectious irritations of the vulva. As 
mechanical irritations, may be mentioned masturbation and exces- 
sive sexual intercourse, which may be the result as well as the cause 
of pruritus ; also, the wearing of filthy pessaries, uncleanliness of 
the vulva, irritating urine in vesicovaginal fistula? and diabetes, 
and the irritating discharge from malignant growths. Of the 
infectious agencies may be mentioned parasites, including the 
oidium albicans, pediculi, and intestinal worms. Any condition 



218 SPECIAL DIAGNOSIS. 

bringing about passive congestion of the pelvis may cause pruritus 
vulvae in the same manner as hemorrhoids cause pruritus ani. 

It is certain that many of the pelvic lesions may reflexly cause 
itching of the vulva. Pruritus vulvae associated with dryness and 
sensitiveness of the skin suggests the presence of kraurosis of the 
vulva. Disorders of the blood may account for some cases. 
Finally, a small number must be attributed to neurosis, though a 
mechanical cause is always to be sought. 

The diagnosis of pruritus vulvae may be made from the patient's 
complaint of itching, but it is most essential that the cause of the 
pruritus be determined by a general as well as local physical exam- 
ination. 

As a general proposition we may consider pruritus vulvae a symp- 
tom of some general or local lesion. Every case of pruritus should 
suggest the possibility of diabetes, and should call for a urinalysis. 
The presence of irritating vaginal discharges, of worms, and of 
parasites are to be sought. The sexual habit of the patient should 
be a subject of inquiry. 

The one dominating symptom is itching over part or all of the 
vulva. So distressing is this itching that the patient becomes irri- 
table and nervous ; she shuns society, and may even develop into a 
maniac or suicide. The itching is always worse at the menstrual 
period, during sexual intercourse, in warm weather, and after 
physical exertion. 

Local changes in the skin surface of the vulva are commonly 
present and are largely due to scratching. 

Webster and Sanger independently studied the histological 
changes of the skin removed from the affected area. Webster 
found the genital corpuscles of Krause in the clitoris, and called 
them tactile corpuscles. Nerve endings in the form of end bulbs 
were found in large numbers. A fibrosis of the corpuscles of 
Krause, the end bulbs, and nerves were found by Webster and 
confirmed by Sanger. There was a marked small round-cell infil- 
tration in the subepithelial tissues and the superficial epithelium 
was largely removed. 

THE HYMEN. 

A physiological rupture and stretching of the hymen occurs from 
sexual intercourse and childbirth. It is possible for the hymen to be 
merely stretched in admitting the penis or in the passage of the child. 



THE DIAGNOSIS OF DISEASES OF THE VULVA. 



219 



The lacerations occurring from the first coition are usually 
radial, and do not extend to the base of the hymen. It is possible 
for the hymen to be partly torn from its base without tearing its 



Fig. 101. 




CRESCENTIC FRINGED BILABIAL BIPERFORATE 

Different forms of hymen. (Testut.) 



CRIBRIFORM 



Fig. 102. 



Fig. 103. 





Hymen after coitus. (Testut.) Hymen alter parturition. (Testut.) 

Fig. 102. — G. Clitoris. PL. Nymphse. U. Meatus urinarius. OV. Vaginal orifice. H. Hy- 
men. D. Rent in hymen. 

Fig. 103.— U. Meatus urinarius. P. Nympha. CM. Carunculte myrtiformes. Z. Portion or 
hymen, detached and floating. D. A tear through the fourchette. 



free margin. As a rule, there is a circular opening. After child- 
birth the hymen is completely severed in many places, leaving 
isolated tags (caruncula? myrtiformes). These lacerations often 
extend into the vagina and perineum. 



220 SPECIAL DIAGNOSIS. 

The question of the existence or absence of a hymen is of medico- 
legal importance. It is self-evident that the hymen is not a reliable 
guide in judging virginity. The hymen may be present and intact 
after sexual intercourse and even after childbirth ; while, on the 
other hand, it may be totally wanting or but partially developed in 
virgins. It is possible for a lacerated hymen to heal so perfectly 
that no evidence of a previous laceration is visible. 

CYSTS OF THE HYMEN. 

Little is known of cysts of the hymen. Wenkel made the first 
report in 1883. Palm describes a cyst of the hymen measuring 
8 cm. in diameter. The average diameter is about 1 cm. Many do 
not exceed 1 mm. in diameter. They are usually congenital, though 
they may not be observed until late years. One or more cysts are 
located near the free margin of the hymen. 

These various sources explain the presence of a variety of epithe- 
lium lining the cyst cavity. As a rule, the epithelium is squamous 
and stratified, but is occasionally cylindrical, and in a few instances 
endothelium is found. 

The origin of the cysts of the hymen is in many cases the 
epithelial projections. These projections become constricted off, 
and form an epithelial wall of a space which fills with serum. A 
few cases apparently arise from Gartner's duct, from dilated lymph 
spaces, and from retention of the secretions of sebaceous glands. 



CHAPTER XXIII. 

THE DIAGNOSIS OF DISEASES OF THE VAGINA. 
MALDEVELOPMENTS AND MALFORMATIONS. 

Inasmuch as the vagina is partly developed from the ducts of 
Muller, developmental failures, analogous to those found in the 
uterus and tubes, are to be found in the vagina. There may be a 
complete absence or a partial development of the vagina ; the ducts 
of Muller may fail to coalesce, giving rise to a double vagina ; the 
ducts of Muller may coalesce, but fail to be absorbed, leaving a 
partial or complete septum, dividing the vagina in the median line. 

Absence of the vagina may result either from a failure of the 
ducts of Muller to develop or from complete atresia. As a rule, 
the entire Miillerian tract fails to develop, hence the absence of the 
vagina, uterus, and tubes. The appearance of the external organs 
of generation may be misleading in determining the sex. 

Atresia and Stenosis of the Vagina. As a rule, atresia of the 
vagina is incomplete. It is usually the lower segment that is 
closed. In extreme cases only a fibrous or fibromuscular band is 
found between the bladder and rectum. Back of the obstruction 
the menstrual blood collects in the vagina (hsematocolpos) ; in the 
uterus (hsematometra) ; in the tubes (hematosalpinx), and, finally, 
in the pelvis (hematocele). 

The obstructing tissue may be stretched and crowded down, 
appearing at the vulvar outlet as a dark bluish-red membrane. 
The retained blood does not usually coagulate, but becomes dark in 
color. 

Etiology. Atresia of the vagina may be congenital or acquired. 
It may be difficult to determine whether the malformation de- 
veloped in intra-uterine or in extra-uterine life. In very young 
infants a vaginitis may form adhesions of the vaginal surfaces 
without giving rise to symptoms. Whether a foetal vaginitis 
can account for congenital atresia of the vagina has not been 
demonstrated. 



222 



SPECIAL DIAGNOSIS. 



The usual cause of stenosis and atresia of the vagina occurring 
during the period of sexual maturity is trauma incident to labor. 



Fig. 104. 



Fig. 105. 





Fig. 104.— Atresia at the vulva first causes distention of the vagina, producing hsemato- 
colpos. (Sutton and Giles.) 

Fig. 105.— Atresia at the vulva. Hsematotrachelos has followed bsematocolpos. (Sutton 
and Giles.) 



Fig. 106. 



Fig. 107. 





Fig. 106.— Atresia at the vulva has caused heematocolpos, then heematotracheios, and then 
hsematometra. (Sutton and Giles.) 

Fig. 107.— Atresia at the vulva. In addition to the conditions in Fig. 106, there is added 
hematosalpinx. (Sutton and Giles.) 



THE DIAGNOSIS OF DISEASES OF THE VAGINA. 



223 



In the postclimacteric stage an adhesive vaginitis may narrow or 
obliterate the vagina. Gonorrhoea is the usual underlying cause of 
senile vaginitis. In congenital atresia the obstruction is most often 
at the junction of the middle and upper third of the vagina, which 
is the lower limit of the Mullerian ducts. In the acquired form 
the obstruction is usually similarly situated. 

The obstruction may be merely a half moon or annular ring, a 
partial or complete septum with perforations, or a membrane vary- 



Fig. 108. 



Fig. 109. 



Fjg. 110. 








Fig. 108.— Atresia in the vagina midway between the vulva and os externum, causing 
heematocolpos in the upper half of the vagina. (Sutton and Giles.) 

Fk;. 109.— Same as in Fig. 108, except that distention of the whole uterus has followed the 
partial ha?matocolpos. (Sutton and Giles.) 

Fig. 110.— Atresia at the os externum, producing a hsematotrachelos. Corpus uteri not yet 
distended. (Sutton and Giles.) 



ing in thickness even to filling the vagina completely. Two, three, 
and even four atresic points have been described. 

The diagnosis of stenosis and atresia of the vagina should present 
few difficulties. When a girl at the time of puberty fails to men- 
struate, but suffers from pain in the pelvis, which increases in 
severity at the time of each monthly period, atresia of the vagina 
or cervix is suspected. If, in addition, a pelvic tumor develops and 
distinctly fluctuates, the diagnosis is highly probable, but must 
be confirmed by a vaginal examination. Vicarious menstruation 
rarely occurs. In an attempt to make a digital examination of the 



224 



SPECIAL DIAGNOSIS. 



vagina the finger will meet the obstruction. The extent of the 
closure is best determined by the finger in the rectum. If the 
obstruction lies high in the vagina and does not bulge downward it 
is not likely that there is any considerable secretion pent up above 
the point of obstruction. 

Hsematometra is not easy to demonstrate, because of the difficulty 
in palpating the elevated uterus through the rectum. The uterus 
usually lies near the median line, and is rounded, tense, possibly 
fluctuating, and somewhat increased in size. 



Fig. 111. 



Fig. 112. 





Fig. 11 1.— Atresia at the os internum, producing hgematometra. Fallopian tubes may become 
distended later. (Sutton and Giles.) 

Fig. 112.— Atresia at the vulva on one side of a double uterus and vagina, causing heemato- 
colpos on the affected side. (Sutton and Giles.) 

Double vagina is the result of failure on the part of the Mullerian 
ducts to perfectly fuse. From this cause a septum divides the 
vagina in part or throughout. The vaginal canals usually lie side 
by side, the septum running antero-posterior. The canals may be 
unequal in size. The septum rarely runs transversely, so dividing 
the vagina that one lies in front of the other — this can only be 
accounted for on the supposition that the Mullerian ducts had 
rotated prior to their fusion. All degrees of development may be 
observed in the septum, from a slight ridge to a complete partition 
composed of fibrous tissue, mingled with some muscle fibres and 
covered on either side with mucous membrane. The cervix and 
uterine body are usually divided. 



THE DIAGNOSIS OF DISEASES OF THE VAGINA. 225 

If both canals are pervious no symptoms need arise until labor, 
when there may be an obstruction to the passage of the child. 

VAGINITIS (Colpitis). 

Vaginitis rarely exists singly. As a rule, it is associated with 
vulvitis and endometritis, and not infrequently with a similar 
involvement of the entire genital tract. 

Etiology. With few exceptions vaginitis is due to bacterial 
invasion. Mechanical and thermic irritants are accountable for a 
small number of cases. 

Of the micro-organisms causing vaginitis the gonococcus is by far 
the most frequent. A purulent discharge from the cervix contain- 
ing the gonococcus may fail to infect the vagina because of the pro- 
tecting epithelium, which, when intact, resists all bacterial invasion. 

If, however, the epithelium of the vagina is lost or its vitality is 
lowered infection will follow. We, therefore, find primary gonor- 
rhoeal vaginitis less frequently in the young than in advanced 
years, when the epithelium has lost its full power of resistance and 
is more or less desquamated. Repeated attacks of vaginitis may 
result from contamination by the secretions of the uterus, tubes, 
and urethra. 

Injudicious exercise and sexual excesses may be the explanation 
of exacerbations. 

Puerperal vaginitis is nearly always caused by the staphylococcus 
and streptococcus. The Klebs-Loemer bacillus is rarely the cause 
of vaginitis. The streptococcus of erysipelas is occasionally found, 
particularly in infants. The presence of the oidium albicans and 
leptothrix has been demonstrated. Entozoa can invade the vagina 
from the rectum. Ascarides and similar parasites of the intestines 
may invade the vagina and set up a vaginitis. 

Infections from the bowel, as from dysentery and typhoid fever, 
may invade the vagina. Infection may also travel from the 
bladder to the bowel. An irritating and infectious discharge from 
the uterus or from a pelvic abscess opening into the vagina will 
infect the vagina. It is highly probable that maceration of the 
epithelium by fluids used in douching favors infection from such 
discharges. 

The secretions from malignant growths of the uterus are particu- 
larly irritating to the vaginal mucosa. 

15 



226 SPECIAL DIAGNOSIS. 

Trauma from ill-fitting and foul pessaries, from tampons saturated 
with irritating secretions, and from masturbation predisposes to 
infection. 

Shultze has correctly claimed that decomposition of stagnated 
menstrual blood behind the hymen in chlorotic girls is not infre- 
quently a cause of vaginitis. 

Tumors lying within the vagina may act as mechanical irritants 
to the vaginal mucosa. 

Anatomical Diagnosis. The following morphological forms are 
recognized : 

1. Catarrhal vaginitis is recognized by a reddening, swelling, and 
increased secretion of the vaginal mucous membrane. These 
changes are proportional to the degree of acuteness and intensity of 
the infection. The surface is rarely uniformly red, but rather 
mottled red and gray. In the chronic stage slight reddish eleva- 
tions stud the surface. These elevations are particularly prominent 
in old age, when contrasted with the smooth, pale gray background. 

The microscope shows a diffuse round-cell infiltration, and capil- 
lary congestion of the subepithelial connective tissue. There may 
be more or less desquamation of the surface epithelium. The deep 
layers of connective tissue are rarely involved. In the senile variety 
punctate hemorrhages are particularly liable to occur in the 
connective tissue. Gebhard speaks of a variety called croupous 
vaginitis, in which there is formed on the surface a false membrane 
composed of fibrin, leucocytes, desquamated and degenerated 
epithelium. He observes that a similar lesion is often found in the 
bowel, and reasons that there is a specific cause underlying both 
conditions. 

2. Ulcerative Vaginitis. It is possible for ulcers to develop in 
the advanced stage of catarrhal vaginitis ; this, however, is excep- 
tional. The loss of epithelium is usually superficial, and in healing 
does not lead to cicatrization. 

a. Puerperal ulcers of the vagina arise from infection of abrasions 
and lacerations acquired in labor. A diphtheritic membrane of 
a gray or yellowish-gray color forms over the ulcerated surface. 
The lesion may extend deeply into the vaginal wall and into the 
paravaginal connective tissue. Pelvic abscesses and suppurative 
peritonitis may follow from extension of the infection. A diffuse 
tumefaction and reddening of the vaginal mucous membrane may 
extend from the ulcers, giving the appearance of erysipelas. 



THE DIAGNOSIS OF DISEASES OF THE VAGINA. 227 

Stenosis and atresia of the vagina may follow healing by cicatriza- 
tion, particularly when the paravaginal tissues are involved. 

b. True diphtheritic ulcers of the vagina, in which the Klebs- 
Loeffler bacillus appears, is a rare finding, and almost always 
develops during the puerperium. 

c. Tuberculous ulcers of the vagina are of rare occurrence. Such 
ulcers are shallow, with irregular undermined margins. The base 
and margins are studded with miliary tubercles, in which the 
tubercle bacillus may be demonstrated. 

d. Syphilitic ulcers in the primary stage with elevated indurated 
margins are more common than those of the secondary or tertiary 
stage. 

Ulcers of the vagina complicating the infectious diseases, as, for 
instance, typhoid fever and smallpox, are occasionally seen. 

e. Decubitus ulcers arising from pressure by foreign bodies in the 
vagina show great variation in extent and form. The common 
cause of decubitus ulcers is the wearing of ill-fitting pessaries, 
which, through pressure, causes a superficial slough of the mucosa. 
The necrosis may extend deep into the tissues and result in the 
development of a vesicovaginal fistula. Such ulcers may attain 
the size of a saucer. 

3. Tuberculous Vaginitis. But one case of primary tuberculosis 
of the vagina has been reported (Friedlander). The usual tuberculous 
lesions are found — that is to say, local or general dissemination of 
tubercles, larger tuberculous nodules, and caseous masses with ulcers. 

The microscope reveals the usual structure of tubercles : giant 
cells, small round cells, endothelioid cells, and tubercle bacilli. 

By far the greater number are secondary to tuberculosis of the 
uterus, tubes, vulva, cervix, rectum, and bladder. The lesion 
may very rarely be conveyed by the blood. Primary infection may 
be acquired by direct infection from the husband and from the 
examining finger and instruments. 

4. Emphysema vaginae (colpitis emphysematous). As the result of 
some sort of an infection numerous small cysts filled with gas are 
found in the subepithelial connective tissue. The lesion usually 
appears in pregnancy and the puerperium. As a rule, the cysts 
disappear within three months after labor. 

Wenkel first described them as retention cysts formed from 
vaginal glands. Zweifel first demonstrated them to be the result of 
fermentation. Eisenlohr proved the presence of gasogenic bacteria 



228 SPECIAL DIAGNOSIS. 

in the connective tissue spaces of the submucosa and of the lymph 
spaces. There can be no doubt as to the microbic origin of the 
lesion. 

Through a speculum the vesicles appear dark, bluish-red in color. 
Pressure causes them to temporarily disappear. If the vagina is 
partly filled with clear fluid and the vesicles punctured with a 
needle, gas will escape in bubbles. 

5. Condylomatous Vaginitis. Groups of warty excrescences are 
found in the vagina as further extension of a similar growth of the 
vulva. The whole vaginal surface may be covered with the warty 
growth. 

Clinical Diagnosis. In all forms of vaginitis there is an exces- 
sive secretiou, varying in quantity and character. The secretion 
is derived in part from the uterus and cervix. It is serous, 
mucous, or purulent. This so-called leucorrhoea (" whites") is 
usually the first symptom. Following this is itching and burning, 
which is aggravated by exercise. When caused by gonorrhoea 
these symptoms may appear within twenty-four hours from the 
time of the infection. In addition to the above symptoms there is 
usually burning and smarting on urinating, caused by a urethritis. 

When pus can be expressed from the urethra the diagnosis of 
gonorrhoea is made with reasonable certainty. If in addition the 
Bartholinean glands are infected, there can be little doubt as to the 
gonorrhoeal origin of the lesion. 

Vesical and rectal tenesmus are present in the acute stage. In 
the mild forms and in the chronic stage the patient may not 
complain. 

The diagnosis has to do, first, with the recognition of the vagin- 
itis ; next, with the possible extension of the lesion to neighboring 
structures; and, finally, with the underlying cause of the infection. 

Direct inspection should determine the presence of vaginitis. 
The Sims speculum should be used with the patient in the Sims 
position. There is more or less sensitiveness to the touch of the 
examining finger, and a roughness of the surface may be detected. 

The recognition of extension to the upper genital tract involves 
the diagnosis of endometritis and salpingitis. To determine whether 
the secretion is from the vagina or from the uterus the Shultze 
method is employed. The vagina is cleansed with a douche of 
sterile water, a plug of sterile cotton is placed against the cervix, 
and after remaining there several hours it is removed. If the secre- 



THE DIAGNOSIS OF DISEASES OF THE VAGINA, 229 

tion is collected on the top of the plug, the discharge comes from 
the uterus ; if it collects around the plug, the discharge is from the 
vagina. 

Recognition of the cause of the infection is not always possible. 
Gonorrhoea is so frequently the cause that it must first be excluded 
before considering other possible causes. In the acute stage the 
gonococcus can usually be found in the secretion, but not often in 
the chronic stage. When beginning a few days after marriage and 
associated with burning on urinating, it is highly probable that 
gonorrhoea is the underlying cause. 

PARAVAGINITIS. 

By paravaginitis is understood an inflammation involving the 
connective tissue immediately surrounding the vagina. As a rule, 
it is a staphylococcus infection leading to the formation of localized 
abscesses. Other possible causes are wound infections following 
operations and attempts to induce abortion ; ill-fitting pessaries, 
which have ulcerated through the vaginal wall ; infectious diseases, 
such as dysentery and typhoid fever, where the infection is con- 
veyed through the bowel or bladder into the paravaginal connective 
tissue, and in all inflammatory diseases of the rectum and bladder 
extending to the vagina. 

Veit describes a peculiar form which he designates as paravaginitis 
phlegmonosa dessecans. But few cases have been recorded. One 
was ascribed to gonorrhoea ; others may have been due to criminal 
abortion, and in two instances no cause was assigned. Undoubtedly 
the lesion may arise as a complication of contagious and infectious 
diseases. Cicatricial contraction of the vagina is the final result. 

NEW FORMATIONS OF THE VAGINA. 

Cysts of the Vagina. Cysts of the vagina are not of great 
rarity. Nengebauer found thirty-six cases in 600 observations. 

Histogenesis. The fact that the epithelial lining of the cysts 
varies in form suggests various origins. Veit believed them to 
develop from remains of the Wolffian ducts. The ducts of Gartner 
do not ordinarily extend below the vault of the vagina, but 
instances are known in which they extended as far as the urethral 
opening along the lateral and anterior walls of the vagina. In 



230 SPECIAL DIAGNOSIS. 

these ducts muscle fibres and cylindrical epithelium are observed, 
and so it is that cysts located in the sides or in the anterior wall of 
the vagina and containing muscle fibres and epithelium are assumed 
to arise from the ducts of Gartner. As further evidence of this 
origin, may be mentioned their occasional elongated form with their 
long axis in a line corresponding to the long axis of the vagina. 
Still more significant is the rosary-like arrangement of two or more 
cysts along the line of Gartner's duct. 

Preuschen suggests that the origin of vaginal cysts may be the 
glands of the vagina. Cysts lying in the posterior wall of the 
vagina are thus explained. They are regarded as retention cysts. 
Davidson holds that the glands of the vagina are purely misdevel- 
opments. Those in the upper segment of the vagina are misplaced 
from the cervix and maintain the character of cervical glands, while 
those in the lower segment of the vagina are from the vulva. 
Retention cysts arising from these glands are usually multiple, of 
small size, and lined with a single layer of columnar epithelium. 
Cysts may arise from partial adhesion of the folds of vaginal mucous 
membrane enclosing spaces lined with flat epithelium. 

Freund believes that cysts of the vagina arise from rudimentary 
ducts of Muller. Furthermore, it is apparent that the lymph spaces 
may distend into cysts lined by endothelium. 

Cysts of the vagina are rarely of large size, ranging from that of 
a pinhead to a hazelnut. In exceptional cases they are found the 
size of a child's head. They are slow in growth. The sites of 
election are the anterior and lateral walls, rarely the posterior wall 
of the vagina. They lie immediately underneath the epithelium, 
and bulge into the vagina. The consistency is elastic ; the contents 
clear, watery, or mucoid. Occasionally the contents are milky from 
the presence of degenerated epithelium ; sometimes chocolate color 
from admixture with blood. Cheron reports the presence of a stone 
in the cysts. Cholesterin crystals are occasionally found. As 
a rule, the cysts are simple, but they may be multilocular. The 
cyst wall is composed of fibrous tissues, occasionally mingled with 
some muscle fibres. The inner surface is lined with a single layer 
of cylindrical epithelium, sometimes with several layers of cylin- 
drical or flat epithelium ; rarely are endothelial cells found. 

They are seldom of clinical interest, but are known to interfere 
with sexual intercourse and with childbirth. 



THE DIAGNOSIS OF DISEASES OF THE VAGINA. 231 



FIBROMYOMA OF THE VAGINA. 

Richard R. Smith collected 101 cases from the literature. They 
commonly occur between the ages of twenty and forty years, and 
have been observed as early as one and one-half years and as late as 
seventy-eight years. The largest one recorded weighed ten pounds. 
They are usually round and attached by a broad base or pedicle. 
The surface is smooth or nodular, and is covered with vaginal 
mucous membrane. They are seldom of soft consistency. Their 
origin is in the submucous connective tissue. They are rarely 
multiple, and are most often located in the anterior wall of the 
vagina. The usual forms of degeneration common to fibroids are 
possible. 

The diagnosis is not difficult. A soft fibroid might be mistaken 
for a cyst, a cystocele, or a rectocele. The bluish, semitransparent 
color of the cyst is of special significance. 

CARCINOMA OF THE VAGINA. 

Etiology. Less than 1 per cent, of all cancers in women are of 
vaginal origin (Williams, Bristol). Kiistner collected twenty-two 
cases of primary cancer of the vagina, and estimates that about 
0.02 per cent, of cancers of the genital tract arise primarily in the 
vagina. 

As a rule, primary carcinoma of the vagina arises between the 
ages of fifty and sixty ; two cases are reported at twenty years of 
age. Childbearing does not influence the development of the 
growth, and heredity plays a minor role. A number of cases have 
been recorded where ill-fitting pessaries have caused ulceration and 
eventually malignant degeneration. Prolapse of the vaginal walls 
subjects the vagina to mechanical insults, and upon the injured 
surface may be engrafted a carcinoma. 

Anatomical Diagnosis. In 123 cases 71 were found on the 
posterior vaginal wall, 13 on the lateral walls, and 16 were annular. 
The growth may be papillary, nodular, or infiltrating. To the 
unassisted eye cancer of the vagina usually presents a thickened, 
ulcerated area. The margins are irregular, hard, and elevated. 
The base of the ulcer is uneven, bleeds freely on handling, and 
is covered with a foul-smelling secretion. Surrounding the vagina 



232 



SPECIAL DIAGNOSIS. 



the tissues show an inflammatory reaction, and secondary nodules 
may be seen distributed over the surface. Rarely does the growth 
attain the size of a man's fist. Extension into the paravaginal 
tissue is rapid. Reaching the lymph spaces of the connective tissue, 
the cancer cells are rapidly carried to the retroperitoneal glands. 
The inguinal glands are enlarged when the lower segment of the 



Fig. 113. 




Carcinoma of vaginal wall. (Dudley. 



vagina is invaded. . As a rule, the uterus is not invaded so early 
as the vulva, and metastasis to distant organs is late. The micro- 
scope shows nothing unusual. It is a flat-cell growth, the cells are 
arranged in nests, and contain many pearls. 

Clinical Diagnosis. The lesion may go unrecognized until far 
advanced. As with cancer of the uterus, all symptoms may be 
wanting until there is ulceration and sloughing of the growth. 



THE DIAGNOSIS OF DISEASES OF THE VAGINA. 233 

Hemorrhage, pain, and a foul-smelling discharge are the cardinal 
symptoms, but in no way do they differ from the same group found 
in cancer of the vulva or uterus. Pain is rarely present until the 
growth has extended into the paravaginal tissue. All observers 
have noted the absence of pain in the early stage. 

Stenosis of the vagina may hide a growth lying above the point 
of constriction, and render the early diagnosis very difficult. 

Secondary cancer of the vagina is of frequent occurrence. 
Cancer of the cervix is especially liable to extend to the vagina, 
and normal tissue may intervene between the primary growth in 
the cervix and the secondary growths in the vagina. Cancer of 
the bladder and rectum more rarely invade the vagina. Metastatic 
growths from the ovary are seldom found in the vagina. 

Wahn, Fisher, and Kalkenbach report implantation of cancer 
cells upon eroded surfaces in the vagina through the medium of a 
leucorrhceal discharge. The secondary growths take the same his- 
tological forms as the primary growth. 

The average duration of primary cancer of the vagina is said to 
be sixteen months, but may last several years. 

Differential Diagnosis. Decubitus ulcers caused by ill-fitting 
pessaries may be mistaken for carcinoma, and have known to be its 
starting-point. The hard, elevated margins friable, and bleeding 
when handled, are distinctive of malignancy. Where doubt exists 
a microscopic examination of an excised piece, or a scraping from 
the suspected portion, will determine the diagnosis. 

Syphilitic and tuberculous ulcers of the vagina are recognized by 
the clinical history, by evidences of lesions elsewhere in the body, 
and by microscopic examination of excised pieces. Friability and 
bleeding of the suspected tissue are suggestive of carcinoma. 

SARCOMA OF THE VAGINA. 

Sarcoma of the vagina is found in all ages, from the first to the 
eighty-second year. Six so-called congenital cases are reported. 
Of forty cases reported by ^Yilliams, thirty-six occurred before 
fifteen years of age. 

The growth is usually polypoid, of a yellowish-gray or chocolate 
color. Rarely is there a diffuse infiltration of the vaginal walls. 
The surrounding structures are early invaded. Distant metastasis 
is late, and often does not occur. There is a tendency to early 



i 



234 SPECIAL DIAGNOSIS. 

necrosis of the tumor mass, together with infection of the necrotic 
mass by pyogenic micro-organisms leading to cystitis, pyonephritis, 
and peritonitis. Late in life sarcoma is usually smooth rather than 
rough and polypoid as in early life. 

Histologically, the growth is demonstrated to be a fibrosarcoma, 
myxosarcoma, round-cell or spindle-cell sarcoma, or, finally, a 
melanosarcoma. 

The diagnosis of sarcoma apart from carcinoma cannot be made 
without the aid of the microscope. 

SYNCYTIOMA VAGINA. 

Syncytioma malignum (or, as better named, chorio-epithelioma 
malignum) occurs with relative frequency as a secondary growth in 
the vagina. 

Schmidt lately reported two cases of primary growths in the 
vagina. Tn both cases the uterus remained perfectly normal. 

I am indebted to Dr. Frank Pierce for the microscopic section 
from which Plate XXXII. was drawn. 

All new-growths of the vagina developing weeks and months 
after labor should be excised and examined, with special regard for 
malignant proliferation of the syncytium. 

To the unaided eye the tumor is usually round and elevated. It 
is of a bluish color. Ulceration is rare. On cross-section the 
tumor is exceedingly bloody, and may resemble a blood clot. 

ENDOTHELIOMA OF THE VAGINA. 

Endothelioma of the vagina is an exceptional growth. The first 
case was reported by Klein. By the naked eye the growth cannot 
be distinguished from a carcinoma. Microscopically the tumor is 
found to be composed of cells resembling flat epithelium arranged 
in a thick meshwork of connective tissue. The cells arise from the 
endothelium of the blood or lymph spaces. In distribution they 
resemble veins of marble. 



PLATE XXXII 







* *i\ 



■*""«' / ^irvvi'-V : ".:"''' ; c ; :v,'' v . r :' -^-Vt- , N - : ? '.".If.-.,..,.., 



^ 



Chorio-epithelioma Malignum of the Vagina. 

A nodule appeared in the wall of the vagina several months after 
an apparently normal labor. The ease was reported by Schmidt, of 
Vienna. The accompanying illustration was drawn from a section 
of the nodule loaned from the collection of Dr. Frank D. Pierce. It 
represents a covering of normal stratified squamous epithelium.. 
Beneath this is a variable thickness of connective tissue overlying a 
large clot of blood in which are seen two villous stems covered by 
proliferating syncytium. Syncytial cells are seen to invade the blood 
clot. 



CHAPTER XXIV 



ENDOMETRITIS. 



Matthews Duncan once said in a lecture : " Who can tell 
what any one means by endometritis ? Often its use is the parent 
or child of ignorance and confusion ; often it is the cloak of con- 
fusion." There is yet to be proposed an exact and practical classi- 
fication of endometritis. In the light of our present knowledge we 
are unable to harmonize our clinical, macroscopic, and microscopic 
forms of endometritis. In making a diagnosis from prominent 
symptoms and evident etiological factors we are unable to foretell 
the naked eye and microscopic findings. One and all of the 
pathological forms of endometritis may exist without clinical 
signs. On the other hand, any of the pathological lesions of the 
endometrium may give the same clinical manifestations as endome- 
tritis. Furthermore, these symptoms may be present in the 
absence of an evident pathological change in the endometrium. 

It is evident that a clinical classification cannot be universally 
applied. While appropriate to the majority of cases, there will be 
a minority which can only be recognized by direct examination 
of the endometrium with the naked eye or with the microscope. 
Indeed, it not infrequently occurs that the absolute diagnosis is 
reserved for a microscopic examination of scrapings removed by the 
curette. In view of what has been said there will be given both 
a clinical and an anatomical classification. 

Clinical Classification. Endometritis may be acute or chronic. 
The distinction between these forms is usually not difficult to 
make. 

1. Acute Endometritis. In acute infections of the endometrium 
the constitutional disturbances may be mild or severe. Fever may 
exist, but is not always proportionate to the extent and intensity of 
the inflammation. The pulse rate corresponds to the degree of 
general intoxication, and is to be regarded as a more reliable indi- 
cation of systemic infection than is the temperature. The menses 
are lessened or suppressed. The uterine discharge is at first serous, 



236 SPECIAL DIAGNOSIS. 

later seropurulent. There is backache, nausea, a sense of weight in 
the pelvis, rectal and vesical tenesmus, and pain in the hypogas- 
trium. Bimanual examination reveals a uterus tender to pressure, 
not perceptibly increased in size, and perfectly movable. The 
external os may be slightly patulous and softer than is normal. 
Inspection through the speculum shows a congestion of the cervix 
which is particularly evident at the external os. From the 
cervical canal flows a seropurulent or mucopurulent secretion, 
rarely it is clear serous or mucous. A sound introduced into 
the uterus would cause some pain and bleeding, and should not 
be used. 

2. Chronic Endometritis. For practical clinical purposes we will 
adopt a classification of endometritis based upon the prominent 
clinical symptoms — hemorrhage, leucorrhoea, and pain, and will 
speak of hemorrhagic, catarrhal, and dysmenorrhoeic endometritis. 

Clinical Forms of Chronic Endometritis. 1. Hemorrhagic 
endometritis is characterized by an unusual loss of blood during 
and sometimes between the menstrual periods. Inasmuch as the 
normal limits of menstruation vary widely, it is difficult to fix the 
exact limitations of the normal and the abnormal flow of blood. 

The normal limits in time may be fixed from two to eight days ; a 
flow continuing longer than eight days may be regarded as patho- 
logical. The average normal quantity of menstrual blood is six to 
eight ounces. Intermenstrual bleeding is always pathological and 
demands careful inquiry into the cause. It is unusual for endo- 
metritis to cause intermenstrual bleeding. Physical exertion may 
excite hemorrhage, but the loss of blood is never considerable. In 
hemorrhagic endometritis, leucorrhoea and pain may be present, 
but are symptoms of less prominence than is the hemorrhage. 

2. Catarrhal endometritis is characterized by an excessive serous 
or seropurulent discharge from the uterus. The amount of secre- 
tion is not proportionate to the extent and degree of inflammatory 
change found in the endometrium. If mucus is found in the secre- 
tions the cervix is involved, there being no mucous secretion from 
the body of the uterus. 

To differentiate a uterine discharge from the secretions of the 
vulva and vagina the Shultze method should be adopted. (See 
page 228.) 

Not infrequently women complain of a leucorrhoeal discharge 
during pregnancy, and immediately preceding and following the 



ENDOMETRITIS. 237 

menstrual flow. Such are within normal limits, and are to be 
regarded as hypersecretions of the congested uterus, vagina, and 
vulva. 

The most excessive discharge is found in gonorrhoea! endometritis. 
Nothing can be ascertained respecting the essential cause of the 
infection from the macroscopic appearance of the discharge. Cover- 
slip preparations may contain the gonococcus. 

3. Dysmenorrhoeic endometritis is characterized by painful men- 
struation. Pain is little to be relied upon in the diagnosis of 
endometritis. The diagnosis is arrived at by excluding all other 
possible causes of pain. The pain of endometritis is described as 
being of a cramping, bearing-down character, and associated with 
a feeling of weight in the pelvis. However, there is nothing 
characteristic in the pain. More often it is caused by such com- 
plicating lesions as salpingitis, ovaritis, and perimetritis. 

While the above-named symptoms — hemorrhage, leucorrhoea, 
and pain — are commonly present in endometritis, and while one of 
the three symptoms usually dominates and justifies the terms as 
given above, it is not uncommon for endometritis to give rise to no 
symptoms. Furthermore, carcinoma, sarcoma, submucous polyps, 
and retained placental tissue may closely simulate endometritis in 
their clinical manifestations. 

In addition to the above clinical forms of endometritis may 
be mentioned several varieties which are not only hemorrhagic, 
catarrhal, or dysmenorrhoeic, but are deserving of special designa- 
tion because of some point of interest relating to their etiology, 
time, and manner of occurrence. The following forms are ordinarily 
recognized : 

Tuberculous endometritis often follows a primary infection of the 
tubes. Where tuberculous salpingitis is recognized, and there 
develops a catarrhal discharge from the uterus, the extension of the 
tuberculous process to the endometrium is suspected. Cover-slip 
preparations should be taken from the secretions and an explor- 
atory curettage may be made, with the view of finding giant cells, 
tubercles, and the tubercle bacillus in the scrapings. 

Gonorrhceal endometritis can be recognized with absolute certainty 
only by finding the gonococcus in the catarrhal secretion. It is 
not always possible to demonstrate the presence of the gonococcus 
in the secretions ; this is particularly true of the long-standing 
cases. When a leucorrhoeal discharge appears shortly after mar- 



238 



SPECIAL DIAGNOSIS. 



riage, and when in addition to leucorrhcea there is burning on 
urinating and infection of the urethra and glands of Bartholin, 
little doubt can be entertained as to the nature of the infection. 
No other form of endometritis causes such profuse discharge. 

Decidual endometritis is a term applied to the inflammation of the 
endometrium of pregnancy. The lesion can only be suspected 
during pregnancy. A positive diagnosis is made by a microscopic 
examination of the decidua after the expulsion of the foetus. 

Pig. 114. 




Uterus from patient dying on tenth day from a mixed infection— streptococcus and 
colon bacilli. (Jewett.) 



Gonorrhoea is the usual cause. The symptoms are hemorrhage, 
which varies in amount and may continue throughout pregnancy ; 
leucorrhoea of a serous character, sometimes known as hydrorrhoea 
gravidarum ; and pain of a cramping or bearing-down character. 
Decidual endometritis may arise previous to pregnancy and is one 
of the potent causes of abortion. 

Puerperal endometritis occurs in the puerperium as the result of 
instrumental or digital infection. It is not infrequently of gonor- 
rhoea! origin. 






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ENDOMETRITIS. 



239 



Postabortive endometritis follows abortions usually as the result of 
instrumental or digital infection. 

Exfoliative endometritis (membranous dysmenorrhea) is recog- 
nized clinically by the periodic expulsion of a membrane from the 
uterus, either as a' cast of the uterus or in the form of shreds. 
Expulsion of the membrane is accompanied by severe pain. For 
differentiation of this from other discharged membranes, see 
page 121. 

Fig. 115. 




Uterus from patient dying on tenth day from a pure streptococcic infection. (Jewett 



Senile endometritis, as the name implies, occurs in advanced years, 
and in its clinical manifestations (hemorrhage, leucorrhcea, and 
pain) may very closely simulate carcinoma. There is no satisfac- 
tory explanation of the etiology of senile endometritis. 

Fungous endometritis (Olshausen) differs clinically from other 
forms by the presence of severe hemorrhage, and the absence of 
pain and usually of leucorrhcea. 



240 SPECIAL DIAGNOSIS. 

While the above forms are commonly recognized without diffi- 
culty, there is a minority of cases in which endometritis is only 
distinguished by anatomical (gross and microscopic) observations. 
It is evident that an additional classification based upon anatomical 
findings will serve where the clinical signs fail. 

Anatomical Classification. A variety of forms of endometritis 
is recognized by the microscope and the unaided eye. 

Fig. 116. 






■c.v^HKEftf 



The endometrium is thickened, soft, and folded. In the cervix are several distended glands, 
forming a cystic protrusion. 

I. Macroscopic forms of endometritis are diagnosed after the uterus 
is removed and opened. Such findings may be wholly unsuspected 
in the absence of all clinical symptoms of endometritis. The fol- 
lowing forms are recognized by the unaided eye : 

a. Hypertrophic endometritis, in which the endometrium is 
thickened and soft. 

b. Fungous endometritis, in which the endometrium is thrown 
into folds and fungosities. 

c. Villous endometritis, in which the surface of the endometrium 
is covered with shaggy villosities. 



ENDOMETRITIS. 241 

d. Polypoid endometritis, in which one or more mucous polypa 
project from the endometrium. 

e. Ulcerative endometritis, in which true ulcers are formed in 
the endometrium. These ulcers show either a virulent form of 
infection or malignant degeneration. 

/. Pseudodiphtheritic endometritis, following labor and abortion. 
On the surface of the endometrium is a necrotic layer formed of 



^f.*,,.*^ ^. w »"™"'»i» '«*, 



U 



Fig. 117. 



**\H '<->■. 



Normal endometrium of a young woman. The surface is covered -with a single layer of low 
columnar epithelium. The glands are tubular, wavy, lined with columnar epithelium similar 
to that of the surface, and extend to the musculature. They run almost at right angles with 
the surface of the endometrium. The connective tissue is embryonal in type, and contains 
but few small bloodvessels, difficult to demonstrate. 

fibrin, degenerated epithelium, leucocytes, blood, and micro- 
organisms. 

II. Microscopic Forms of Endometritis. The importance of the 
microscope in the diagnosis of endometritis has been alluded to. It 
may be said that the microscope affords the only means of making 
a positive diagnosis of these cases. Without the aid of the micro- 
scope and relying upon clinical signs and symptoms, not only may 

16 



242 SPECIAL DIAGNOSIS. 

the diagnosis and prognosis be faulty, but the uterus may be 
sacrificed in the treatment of what appeared to be a malignant 
growth. Furthermore, life may be sacrificed from failure to remove 
a malignant growth in which the characteristic symptoms were 
absent or suggestive of endometritis. In order that no serious over- 
sight be made, it is important that a systematic microscopic exami- 
nation be made of all uterine scrapings. 

Two general forms of endometritis are recognized by the micro- 
scope — the glandular and the interstitial. The two forms are very 
commonly associated. 

a. Glandular endometritis is characterized by an increase in size 
or number, or both, of the glandular elements. The surface of the 
endometrium is thrown into irregular elevations, forming folds, 
fungosities, villi, or polyps. 

By the increase in size and number of the secreting epithelial 
cells the glands become enlarged and irregular in their course. The 
interglandular spaces are decreased proportionately to the increase 
in the glandular elements. The glands which in normal conditions 
rarely penetrate into the musculature will, when hypertrophied, 
penetrate this region to a limited degree. The distortion of the 
glands may be extreme. In longitudinal sections the glands may 
appear to twist like a corkscrew. The inversion and eversion of 
the glandular epithelium may give to the gland a serrated appear- 
ance. 

The glands are not only increased in size (hypertrophic glandular 
endometritis), but may be increased in number (hyperplastic gland- 
ular endometritis). The increase in the number of the glands is a 
result of a budding from preformed glands, or of invaginations of 
the surface epithelium. 

If we fail to satisfactorily classify the established forms of endo- 
metritis, how much more difficult it is to draw the line sharply 
between inflammatory growths of the endometrium and true tumor 
formations. 

Are we to recognize a benign adenoma of the uterus ? Are the 
mucous polyps to be classified as new-growths or as polypoid forms 
of endometritis? In short, is it possible to define the so-called 
hyperplastic glandular endometritis from benign adenoma of the 
endometrium ? 

Kef erring to general pathology, we are unable to distinguish 
hyperplastic glandular growths of inflammatory origin from benign 



PLATE XXXIV. 



£ 



I 



M 



CWWAHJUR 



Cystic Hyperplastic Glandular Endometritis. 

E. Surface epithelium. 

C. Cystic space formed, from a dilated gland, lined, by a single 

layer of columnar epithelium and. filled, with serum. 

D. Group of small round cells. 

H. Cross-section of a gland lying within the musculature. 

M. Musculature. 

B. Congested bloodvessels. 



ENDOMETRITIS. 243 

adenomata. In reviewing the opinions of a number of authors it 
becomes evident that to separate the two would be impossible, and 
to admit of a connecting link between the two lesions is admis- 
sible. 

Rindfleisch, Chiari, AVeichselbauni, and Orth favor the view 
of simple inflammatory hyperplasia to the exclusion of benign 
adenoma of mucous surfaces. Thoma, Eppinger, and Ponfick 
recognize adenoma, while others, as Van Heukelom and Birch- 
Hirschfeld, believe in the existence of a connecting link between 

Fig. 118. 



£3 



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* ' - -o- ; -" 



tf 

y 



CvYVv< x HN*\ 

Normal endometrium of a woman in the postclimacteric period. The connective tissue is 
more compact and mature ; the glands are small and far separated. 

these lesions. All believe in the inflammatory origin of mucous 
polyps. Polyps of inflammatory origin are found in the stomach 
by Klebs. Birch-Hirschfeld, Petrow, and Landel describe diffuse 
and circumscribed growths of the gastro-intestinal tract due to 
catarrhal inflammation. By a careful analysis of their reports it is 
evident that inflammatory hyperplasia of mucous surfaces merges 
insensibly into tumor growths both benign and malignant. In a 



244 SPECIAL DIAGNOSIS. 

large percentage of their cases carcinoma was associated in the same 
organ. 

In the urinary tract Stoerck, Cahen, Rehn, and Kaufmann 
recognize papillomata of inflammatory origin. 

Le Count says : " It is especially concerning tumors of the 
Fallopian tube that confusion has arisen ; there has been quite a 
general failure to recognize that a diffuse hyperplastic inflammation 
is possible — a process that is strictly analogous to the polypous 
hyperplasia of other mucous surfaces — and that in certain typical 
examples it is as distinct from tumor growth as gastritis proliferans 
is from carcinoma of the stomach." He believes it to be fully 
demonstrated that there exists an imperceptible transition of hyper- 
plastic processes of the tubal mucosa into those of true tumor 
growth, and that these may terminate in the production of benign 
tumors. 

If, then, there is no unanimity of opinion among general path- 
ologists, it is not surprising that the same discrepancy exists among 
gynecologists in reference to similar lesions in the endometrium. 

We find Pozzi, Olshausen, Doderlein, Gebhard, and Huge failing 
to recognize benign adenoma of the uterus, and classifying them 
all as inflammatory hyperplasia, reserving the term adenoma for 
malignant glandular growths. 

Herman gives as his reasons for discrediting the inflammatory 
origin of these growths — first, that pus would be secreted if it were 
inflammatory ; second, recovery would ensue if it were genuine 
endometritis ; third, severe hemorrhage would not occur if it were 
endometritis. He, therefore, speaks of polypoid and hyperplastic 
or diffuse adenoma. The fallacies of his reasoning are too evident 
to demand consideration. 

Landau tells us that the increase in the number of glands can 
only occur in adenomata, and never in endometritis • while Geb- 
hard, Ruge, and Doderlein speak of this increase in the number of 
the glands as characteristic of hyperplastic glandular endometritis. 

The conclusion is that the two lesions cannot be clearly differen- 
tiated ; that a connecting link exists between them. Practically 



speaking, 


all are agreed 


that there 


exists a tendency on the 


part 


of inflammatory glandular growths 


to develop 


into benign 


and 


malignant 


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and when 


occurring in 


old age, or ^ 


when 


recurring 


after repeated 


curettage, 


they are to 


be regarded 


with 


suspicion. 













ENDOMETRITIS. 245 

The buds from parent glands may again and again give off new 
glands. We speak of an inverted gland when processes of the 



Fig. 119. Fig. 120. 



ffl 
ffl 






Fig. 121. Fig. 122. 




Fig. 123. Fig. 124. 



Fig. 125. Fig. 126. 



'■-•■ 



Explanation of scheme of gland invagination. Figs. 119 to 125 show longitudinal sections 
of invaginated uterine glands ; Figs. 120 to 126 show cross-sections of the same gland. The 
glands shown in longitudinal section are crossed each by a line showing the plane at which 
the cross-sections are made. Fig. 119 shows the fundus of a gland invaginated with secondary 
eversion. Fig. 125 shows intraglandular papillary invagination of a gland epithelium from 
the side of the gland. Fig. 121 shows simple invagination of the fundus of a gland. Fig. 123 
shows the inner and outer segments regular and the middle segment invaginated. 1 

1 Amann. Mikroskopisch-Gynakologischen Diagnostik. 



246 SPECIAL DIAGNOSIS. 

gland protrude into the lumen ; of an everted gland when the 
processes protrude from the lumen. In the inverted gland cross- 
sections will give the appearance of a gland within a gland — see 
the schematic drawing, page 245. More or less connective tissue 
invariably separates the glands — a fact to be remembered in differ- 
entiating this condition from malignant adenoma. In rare instances 
two or more layers of epithelium are found on the surface of the 



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Interstitial endometritis. The glands are decreased in size and far separated by- 
mature connective tissue. 



mucosa or in the glands. Many layers of squamous epithelium 
have been observed. Such proliferating epithelium is always 
superficial, never passing beyond the basement epithelium, as in 
malignant glandular growths. 

Spontaneous healing of glandular endometritis is possible though 
not probable. At the time of the menopause the hypertrophied 
glands may diminish in size along with contraction of the intersti- 
tial connective tissue. 






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ENDOMETRITIS. 247 

b. Interstitial endometritis is characterized by a hyperplasia of 
the interglanclular connective tissue at the expense of the glandular 
elements. Two stages -are recognized — the acute and the chronic. 



Fig. 128. 





















%« 









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.v»» 



SSSM^S&T - '»** -v,: '..'-.:. ;■.•*♦« 






•- * ■•*.;:■: 



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Tuberculous glandular endometritis. Three giant cells are seen in the section. There is an 
extensive round-cell infiltration and degenerative changes. 



248 SPECIAL DIAGNOSIS. 

Acute interstitial endometritis presents a small round-cell 
infiltration in the stroma, which may be diffused or circumscribed. 
The bloodvessels are congested and a serous or serosanguineous 
exudate permeates the connective tissue spaces. The glands are 
crowded apart by the widening of the interglandular spaces. They 
are irregularly compressed, causing them to be greatly distorted. 
Healing may be perfect from absorption of the exudate, or the 
acute stage may gradually merge into the chronic. 

Acute senile endometritis is described by Dunning, who presents 
the following summary of the anatomical findings : The endo- 
metrium is thickened, the free surface is devoid of an epithelial 
covering ; there is an increase in the vascularity with a peculiar 
arrangement of the small bloodvessels ; there is a small round-cell 
infiltration ; the glandular elements are diminished ; the coats of 
the arteries of the muscularis are degenerated. The presence of 
diseased appendages in both cases reported by Dunning and of a 
mild form of pelvic peritonitis in one case seems to indicate that 
the inflammation tends to extend beyond the limits of the uterus. 

Chronic Interstitial Endometritis. Newly-formed con- 
nective tissue separates the glands. The glands are irregularly 
compressed and may suffer pressure atrophy. In place of the 
embryonal connective tissue normally found in the endometrium, 
there is matured fibrous tissue which first thickens the endometrium 
and later contracts, resulting in a diffuse or localized atrophy of 
the mucosa. The surface of the endometrium becomes irregular. 
Retention cysts may appear in the endometrium from an obstruc- 
tion at the outlet of the glands, causing the glands to distend with 
the secretions. In direct proportion to the distention of the glands, 
the epithelial cells lining them are compressed and may be quite 
flattened. The interglandular spaces may be greatly narrowed. 
When retention cysts are numerous the term cystic glandular endo- 
metritis or cystic interstitial endometritis is applied. 

When the connective tissue spaces are filled and distended by a 
serous or serosanguineous exudate, the term exudative interstitial 
endometritis is applied. Thus, there may be a combination of these 
forms, and one may speak of an hypertrophic and hyperplastic 
cystic, exudative, glandular, and interstitial endometritis — a rather 
formidable name, but nevertheless suggestive. 

Combinations of the glandular and interstitial forms of endo- 
metritis are the rule. It is unusual for either form to exist alone. 



ENDOMETRITIS. 249 

Rarely are the glandular and interglandular tissues uniformly 
involved (diffuse endometritis). 

The diagnosis of uterine scrapings in endometritis is pre- 
eminently satisfactory and reliable. The loose texture of the endo- 
metrium permits easy removal of the mucosa by the sharp curette. 
It is true that the structures composing the mucosa are more or less 
•distorted in the scrapings, and that the deep layers of the endo- 
metrium are seldom found in the removed particles. When we 
consider that the upper strata may show glandular changes and the 
lower, interstitial changes or the upper strata show an inflammatory 
reaction and the lower malignant degeneration, it is evident that 
the microscopic examination of scrapings is not always reliable. 

Little can be definitely learned from the naked eye appearance 
of the scrapings. Large, friable masses, homogeneous in appear- 
ance, of a pale gray color, suggest malignancy. In cystic formations 
the open spaces may be detected by the naked eye. In general, it 
may be said that little that is positive can be learned from a macro- 
scopic examination of particles removed from the uterus by the 
curette. Huge says : " Die Menge des Ausgekratzen, sei sie gering, 
sei sie reichlich, giebt neimals,fur sich schon einer sicheren Anhaltfur 
■die Entsche idung, obwerhlicli malign oder ob nur benign. ,n 

ENDOCERVICITIS (Endometritis Cervicalis). 

Endocervicitis is an inflammatory lesion confined to the cervical 
canal. Part or all of the cervical endometrium may be involved, 
the extent of the lesion varying from a mere inflammatory zone 
about the external os to a diffuse inflammation of the entire surface, 
extending above the internal os and below the external. 

The diagnosis should not be difficult, because of the accessibility 
of the lesion to direct inspection and exploration. The color of 
the inflamed mucosa varies from a bright red to a dull cyanotic 
hue. The surface may be smooth, but is more often granular or 
papillary. The arbor vitse are rounded and partially obliterated. 
By touching the surface with the finger or sound slight bleeding 
may be excited, and it is even possible for spontaneous bleeding to 
occur. Tenacious, glairy mucus covers the surface and may 
effectually plug the cervical canal. The mucus accumulating 
within the cervical canal may cause pressure atrophy of the mucosa 

1 Winter's Gyniikologische Diagnostik. 



250 SPECIAL DIAGNOSIS. 

and thus dilate the canal. The secretion may be clear, transparent 
mucus or may be milky from the addition of leucocytes and 
epithelium. 

Mucous polyps of inflammatory origin protrude from the mucosa 
into the cervical canal and out through the external os into the 
vagina. 

Microscopic examination of scrapings from the cervix is unsatis- 
factory, for the reason that the surface epithelium and glands are 
firmly embedded in connective tissue and are not readily scraped 
away, as is the endometrium of the uterine body. As in endome- 
tritis, we find in the cervix two microscopic forms — the glandular and 
interstitial. 

EROSIONS OF THE CERVIX. 

An erosion of the vaginal portion of the cervix is a mucous patch 
consisting of a layer of columnar epithelium and newly-formed 
glands lying beyond the external os and replacing squamous 
stratified epithelium. Formerly erosions of the cervix were believed 
to be true ulcers, and were vulgarly called " ulcers of the womb." 
We are indebted to Ruge and Veit for the demonstration of their 
true character. The red or bluish color of the mucous patch is in 
marked contrast to the surrounding pale and smooth vaginal 
epithelium. The margins are irregular but sharply circumscribed. 
The extent of the lesion is variable. In nulliparae there is usually 
a mere zone about the external os, while in multiparas the erosion 
may extend far up upon the vaginal portion of the cervix and even 
to the vault of the vagina. Isolated patches may be seen on the 
vaginal portion of the cervix, with normal vaginal epithelium 
intervening. 

Classification. Erosions may be classified as simple, papillary r 
and follicular. 

1. A simple erosion has a smooth surface covered with a single 
layer of columnar epithelium. Newly-formed glands may dip into 
the underlying connective tissue. 

2. A papillary erosion, as the name implies, presents a papillary 
surface. In addition to the surface layer of columnar epithelium 
there are deep invaginations in the form of glands alternating with 
elevations composed of new-formed connective tissue and round 
cells. The new-formed glands vary greatly in number and size 
and secrete abundant mucus. The papillary elevations are in direct 



ENDOMETRITIS. 251 

proportion to the connective tissue hyperplasia and round-cell 
infiltration. 

3. A follicular erosion is characterized by the presence of reten- 
tion cysts, the so-called "Xabothian follicles." These retention 

Fig. 129. 






ifBffw 



w \ 



&£&& 



Transition of squamous epithelium of vaginal portion to columnar epitheliumof cervical 

canal. (Abel.) 

cysts arise from the occlusion of the mouths of the new-formed 
glands in the erosion. They are filled with inspissated mucus. 
To the touch of the examining finger they are likened to the feeling 
of shot under the skin ; to the eye they appear as rounded eleva- 

FlG. 130. 

m 



■ '-'■' ,- ■ ... '■'■' -"''-•<• 

: fll 



clw.W 



Papillary erosion of the cervix. The squamous epithelium has beeu partially replaced by 
columnar epithelium. The surface is uneven and papillary. The tissue is deeply infiltrated 
with small round cells, and new glands are formed by the invagination of the surface 
epithelium. 



252 SPECIAL DIAGNOSIS. 

tions of a gray, blue, or yellow color. In number they range from 
one to a score or more, and may attain the size of a hen's egg, 
though it is unusual for them to distend to a size larger than a 
hazelnut. The epithelium lining the cyst becomes flattened and 
may be entirely lost. 

The Healing of Erosions. We speak of incomplete and of complete 
healing of erosions. By this is meant the replacing of the mucous 
patch with squamous epithelium. 

Fig. 131. 



■ 



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C.WfiHfifft 



Healed erosion of the cervix. Mucous secreting glands are locked in by:many layers of 
squamous epithelium. Formerly the surface was covered by a layer of columnar epithelium 
from which the glands dipped into the connective tissue. The surface epithelium became 
transformed into stratified squamous epithelium and the glands were buried beneath. 

In complete healing of an erosion the surface epithelium and the 
glands of the erosion are completely replaced by squamous epithe- 
lium, thereby restoring the vaginal portion of the epithelium to its 
normal integrity. 

In incomplete healing of an erosion the columnar epithelium on 
the surface of the erosion is replaced by many layers of squamous 
epithelium similar to that of the surrounding vaginal mucosa. 
The glands beneath are not obliterated, but are either locked in 
beneath the squamous epithelium or open directly upon the surface 
now covered with squamous epithelium. 

Healing of an erosion may be effected by metaplasia of the cylin- 



ENDOMETRITIS. 253 

drical epithelium into many layers of squamous epithelium (see 
Fig. 132). 

Differential Diagnosis of Endo cervicitis. A clinical diagnosis 
of endometritis is commonly made from the mucous or mucopuru- 
lent secretion coming from the cervix. It is well to discriminate 
between a hypersecretion of the cervix due to passive congestion 
and a secretion which is the expression of an infection. This, 
however, is not always possible. A mucous secretion seen to leave 

Fig. 132. 



*feh* 



m^ 






"- -|vw/ 



Incomplete healing of an erosion of the cervix. Between two sections ot stratified squamous 
epithelium is a limited amount of columnar epithelium which is invaginated in the form of 
irregular glands. Numerous glands are locked in beneath the squamous epithelium. 

In this case the surface was originally smooth and covered with stratified squamous epithe- 
lium ; the squamous epithelium became destroyed and replaced by a single layer of columnar 
epithelium, from which glands were formed. Subsequently, through a healing process, part 
of the surface epithelium was transformed into stratified squamous epithelium and the glands 
were covered over, as seen above. 



the cervical canal must necessarily come from the cervix, there 
being no mucus in the secretion of the uterine body or Fallopian 
tubes. When pus is mixed with the mucus, there can be no doubt 
as to the infectious origin of the secretion. 

Erosions of the cervix may closely simulate carcinoma. The 
macroscopic appearance may be identical. The differential diag- 
nosis is given in Chapter XXVI. 



254 SPECIAL DIAGNOSIS. 

Ectropion of the lips of the cervix may closely resemble erosions. 
If the lips of the cervix are grasped by tenacula and approximated, 
the reddened surface will roll into the cervical canal and disappear. 
If an erosion is present, there will be no disappearance of the 
reddened zone. 

ULCERS OF THE CERVIX. 

True ulcers of the cervix are of rare occurrence. Formerly 
erosions were regarded as such. 

Decubitus ulcers of the cervix are found in prolapsus of the uterus, 
and as the result of ill-fitting pessaries. Such ulcers may attain 
the size of a silver dollar. They are usually superficial with irregu- 
lar outlines ; the margins are not elevated ; the base is granular, 
firm, and covered by a grayish-yellow secretion. The tendency to 
bleed is not great, as compared with malignant ulcers. Further- 
more, in contrast with carcinoma, there is a marked tendency to 
cicatrization. Under the microscope the epithelium is seen to be 
lost. The base is thickly beset with distended capillaries embedded 
in the meshes of connective tissue and small round cells. This 
round-cell infiltration extends a variable distance into the under- 
lying connective tissue. A structureless, necrotic material may 
collect upon the base of the ulcer. 

Tuberculous ulcers will be described below. 

Cancerous Ulcers. (See Chapter XXVI.) 

TUBERCULOSIS OF THE CERVIX. 

Tuberculosis of the cervix, as a primary lesion, is a rare finding. 
Beyra finds sixty-eight cases of primary tuberculosis of the cervix 
in the literature, and adds a single case. In nine of these cases 
the lesion was confined to the cervix ; in the balance there was an 
invasion of adjacent structures. The greatest number occurred 
between the ages of twenty-one and forty years ; the extreme ages 
were seventeen and seventy-nine. 

Beyra divides the pathological forms into the ulcerative, hyper- 
plastic, and miliary. 

Tuberculous ulcers of the cervix may follow primary tuberculous 
infection of the endometrium ; or, as is more often the case, a 
primary infection of the tubes with subsequent extension downward 
to the uterus and cervix. The diagnosis must be based upon the 



ENDOMETRITIS. 255 

finding of giant cells, of tubercles, and of tubercle bacilli in and 
about the ulcers. The margins of a typical tuberculous ulcer are 
irregular and undermined ; the base of the ulcer is uneven and 
tends to heal by cicatrization. 

Miliary tuberculosis of the cervix has been recognized but three 
times. 

In general, it may be said that tuberculosis of the cervix closely 
resembles erosions and cancer. A positive diagnosis can only be 
made by the aid of the microscope. The clinical history and the 
finding of tuberculosis elsewhere in the body, particularly in the 
upper genital tract, is of importance in the consideration. 

CHRONIC METRITIS. 

Endometritis can scarcely exist without more or less involvement 
of the uterine musculature. In acute affections the muscularis is 
congested, and the connective tissue spaces are filled with a serous 
exudate and a round-cell infiltration. Abscesses may develop in 
the connective tissue spaces and infected thrombi may form in the 
blood spaces. 

In the chronic stage there is a development > 'i connective tissue 
between the muscle fibres. As the connective tissue forms and 
contracts the muscle fibres atrophy, and through this process the 
uterus becomes very firm. 

The diagnosis is based upon the uniform enlargement of the 
uterus and upon the change in its consistency. In the chronic stage 
there may be no tenderness on pressure. 

Chronic metritis may be regarded as a clinical term signifying 
a uterus that is uniformly enlarged, firm in consistency, and one 
which has lost its normal flexibility. 

Chronic metritis is to be diagnosed from interstitial fibroids. 
(See Chapter XXV.) 



CHAPTEE XXY. 

THE DIAGNOSIS OF FIBROMYOMA OF THE UTERUS. 

Etiology. We know nothing of the essential cause of uterine 
fibroids. Heredity has been discussed as a possible etiological 
factor. While there are families in which two or more members 
are known to have fibroids of the uterus, the influence of heredity 
is not to be overestimated. Engstrorn, in 530 cases of uterine 
fibroids, found a similar lesion in the mother or sisters thirteen 
times. 

It is a matter of common observation that the negro race is more 
susceptible to fibroids than the Caucasian. Kelly and Williams 
deny this. In 357 cases reported by Williams, fibroids were only 
2 per cent, more frequent in the colored race. 

The time of occurrence is during the period of sexual maturity, 
the greatest number occurring between the ages of thirty and 
forty. It is most unusual for fibroids to arise before puberty or 
after the menopause. Muller reported 299 cases of uterine fibroids, 
of which number 120 were observed after forty-five years of age. 

It has been observed that virgins and nulliparous married 
women show a greater disposition to fibroids than do multipara. 
On the other hand, sexual excesses are said to favor the growth of 
fibroids. Moller states that 67 per cent, occur in women who are 
not virgins. 

As to the frequency of occurrence, Boyle holds that 20 per cent, 
of women who have reached thirty-five years of age have fibroids, 
while Klobs affirms that 40 per cent, of women who reach fifty 
years of age have fibroids of varying size and number. 

In Veit's Handbuch we read : " So far as the common myo- 
mata (excluding the adenomyomata) are concerned, I hold that their 
origin from an embryonic inclusion has not been proven. It ap- 
pears, however, that heredity plays a role therein ; and one is also 
able to understand that irritation, acting chronically upon the 
uterus, may give rise to the formation of myomata, but the modus 
operandi of the latter is not yet clearly proven." 



THE DIAGNOSIS OF FIBROMYOMA OF THE UTERUS. 257 

Histogenesis. According to Kleinwachrer, fibroids originate 
from round cells found in bloodvessels, which later become oblit- 
erated. The round cells are converted into muscle and connective 
tissue fibres. Bosger believes their origin to be in the muscle 

Fig. 133. 




Multiple myomata. (Dudley.) 



fibre of bloodvessels. Gottschalk is of the opinion that it is not 
the musculature of the bloodvessels that forms the matrix of 
the tumor. He observed amoebic movements in certain proto- 
plasmic bodies which he interpreted to be parasites, and believed 
them to be the essential cause of fibroids. Tedder believed he 



258 SPECIAL DIAGNOSIS. 

discovered animal parasites in uterine fibroids. Virchow believed 
them to be a hyperplasia of the uterine musculature. Judging 
from the above conflicting opinions, it is evident that nothing is 
certainly known of the histogenesis of uterine fibroids. 

The Anatomical Diagnosis of Uterine Fibroids. Under this 
head we will consider the size, form, consistency, rate of growth, 
number, and position of the tumor, and also the microscopic 
structure. 

In size uterine fibroids vary from almost microscopic dimensions 
to the tumor reported by Hunter, weighing 140 pounds. 

The form is smooth and rounded, or, as is more often the case, 
nodular. 

In consistency fibroids vary from soft and semifluctuating to a 
stone-like hardness. Fibroids are classified as hard and soft. 
Hard fibroids consist largely of fibrous tissue with a relatively 
small amount of muscle fibre ; the blood supply is not great. Soft 
fibroids are made up of a relatively large amount of muscle tissue 
and are very vascular. 

The rate of growth of soft fibroids is more rapid than of hard 
fibroids. During pregnancy fibroids grow rapidly. After the 
menopause they usually decrease in size, though the menopause is 
often delayed three to ten years. 

It is exceptional for fibroids to exist singly. As many as 400 
separate and distinct tumors have existed in the uterus. We 
speak of fibroids as single or multiple. 

The position of fibroids in relation to the uterine wall is of the 
greatest clinical importance. .The terms submucous, intramural or 
interstitial, and subserous or subperitoneal are used to designate 
the location of the tumor. All fibroids are originally intramural, 
and as they increase in size they tend to grow in the direction of 
least resistance. For example, an intramural fibroid lying nearer 
the endometrium than the perimetrium will eventually become sub- 
mucous. So long as a fibroid is completely enveloped by the 
musculature, no matter to what extent, it is intramural, but when 
the capsule of the fibroid is immediately covered with peritoneum 
or mucosa it becomes subperitoneal or submucous. When the 
growth sits upon the inner or outer surface of the uterus with a 
broad base, it is known as a sessile growth ; when the base of 
attachment is constricted, it is known as a pedunculated growth. 
The more pedunculated the tumor the slower the growth, because 



THE DIAGNOSIS OF FIBROMYOMA OF THE UTERUS. 259 

of the limited blood supply passing through the pedicle. The 
pedicle when long may so limit the blood supply to the tumor that 
atrophy will result. Twisting of the pedicle may completely 
interrupt the blood supply, in which case the fibroid will become 
gangrenous. If the tumor is adherent to neighboring structures, 
a requisite supply may be conveyed by the adhesions. A partial 
twist of the pedicle may be followed by atrophy or oedema of the 
tumor. 

Spontaneous amputation of the tumor by lengthening or twisting 
of the pedicle is one of nature's means of effecting a cure in sub- 
mucous growths. 

Fig. 134. 




An intraligamentous myoma uteri. (Dudley.) 

Fibromyoma of the cervix occurs in about 6 per cent, of all 
uterine fibromyomata. 

a. Submucous fibromyomata bulge into the uterine cavity and 
are directly covered with mucous membrane. They are either 
pedunculated or sessile, single or multiple, and are seldom as 
large as the patient's head. The pedicle may permit them to pro- 
trude into the cervical canal or further on into the vagina. They 
usually possess a relatively large amount of muscle fibre and blood- 
vessels, and hence are soft in consistency and their growth is rapid. 
When large and soft their form is moulded to that of the uterine 
cavity. They are rarely spherical, but more often elongated. The 



260 



SPECIAL DIAGNOSIS. 



cervix may constrict them into an hour-glass shape. As the tumor 
increases in size the overlying mucosa may be atrophied ; likewise, 
the opposing mucosa of the uterus may suffer pressure atrophy, 
and adhesions may form between the tumor and uterine mucosa. 
This explains the absence of hemorrhage in many of the large sub- 
mucous fibroids. Leyden and Kuster described a case in which a 
fibromyoma having become detached from the uterus adhered 

Fig. 135. 




Submucous fibroid of the uterus. The uterus is evenly distended by a large fibroid. 



firmly to the cervix. Partial inversion of the uterus may be caused 
by traction upon the fundus by a pedunculated submucous fibroid 
attached to the fundus. The effort on the part of the uterus to 
expel the fibroid causes the inversion. 

b. Interstitial fibromyomata lie encapsulated within the uterine 
wall. Rarely are these growths ill-defined from the uterine muscula- 
ture (diffuse fibromyomata). When large the growth bulges upon 
the mucous or serous surface or upon both surfaces. Such growths 



THE DIAGNOSIS OF FIBROMYOMA OF THE UTERUS. 261 



are usually multiple and are seldom so firm in consistency as are 
subserous growths. 

c. Subserous fibromyomata bulge upon the serous surface of the 
uterus. They are single or multiple, commonly firm in consistency, 
though sometimes soft and apparently fluctuating. When pedun- 
culated they may be freely movable, or firmly fixed by adhesions 
which bind the growth to surrounding structures. When located 
at the side of the uterus the growth may develop between the 



gggggfoy 



Fig. 136. 




Intramural, submucous, and subperitoneal myomata. A pedunculated subperitoneal 
myoma is sometimes wrongly called extra-uterine myoma. A pedunculated submucous 
myoma is called intra-uterine polypus. (Dudley.) 

layers of the broad ligament — " intraligamentary or broad ligament 
fibroids." 

Fibroids of the cervix may be submucous, interstitial, or subserous 
(subvaginal). Submucous fibroids of the cervix are seldom large. 
They are usually pedunculated, and as such are known as fibrous 
polyps. 

Interstitial fibroids of the cervix distort the cervical canal, and 
may cause complete obstruction, locking in secretions above and 
preventing conception. 



262 



SPECIAL DIAGNOSIS. 



Subserous fibroids of the cervix are very rare, and are seldom 
of large size. They may grow into the vagina or into the para- 
vaginal connective tissue. 

On cross-section of a fibromyoma bands of fibrous and muscular 
tissue are seen running in various directions and forming whorls, 
concentric rings, and wavy lines. The color varies from gray to 
a^rosy hue, depending upon the relative amounts of fibrous and 
muscular tissue and upon the blood supply. 

Fig. 137; 




Subperitoneal fibroid oi the uterus. The uterus is crowded backward by a fibroid attached to 

its anterior wall. 

The microscopic diagnosis is based upon the finding of mature 
connective tissue and muscle fibres. Without a knowledge of the 
gross appearance of the tumor it is impossible to distinguish a 
fibroid from the uterine wall. The relative amount of connective 
tissue and muscle fibres varies widely. 

A pure fibroid does not exist. There is always present more or 
less muscular tissue. As age advances the connective tissue increases 
at the expense of the muscular elements. The muscle fibres are 







THE DIAGNOSIS OF FIBROMYOMA OF THE UTERUS. 263 

involuntary, and contain spindle-formed nuclei. The cell proto- 
plasm is homogeneous, rarely granular. On cross-section the 
nucleus is half -moon shape. Some fibres contain two or more 



Fig. 138. 






Affl 









GI 

Schematic drawing representing the development of uterine fibroids and their relation to the 
uterine wall. (Suggested by Fehling.) 

AI, AU, AIII. Subperitoneal fibroids. BI, BII, Bill. Interstitial fibroids. 
CI, CII, CIII. Submucous fibroids. 



264 SPECIAL DIAGNOSIS. 

nuclei. Karyokinetic figures are seldom seen in the muscle cells 
of the slow developing growths, but are present in proportion to 
the rapidity of the growth. The connective tissue usually forms 
a loose texture, poor in nuclei. In other growths and in other 
fields of the same growth the connective tissue may be more com- 
pact and contain round or oval nuclei. 

Bloodvessels course through the connective tissue. Veins are 
not as numerous as arteries, particularly in old fibromyomata. A 
central artery running an irregular course through the centre of 
the fibroid is described by Gottschalk, but has not been generally 
recognized. Lorey and Hertz have described nerve fibres in fibro- 
myomata. 

ADENOFIBROMYOMA UTERI. 

Fibroids containing glands are described by numerous authorities. 
Shroeder believes the glands originate in the endometrium. Carl 
Ruge, Gottschalk, Kossman, and others maintain that they arise 
from Gartner's ducts. Recklinghausen contends that the glands 
arise from the Wolffian body or from the endometrium. These 
peculiar growths are almost invariably intramural. They never 
possess a capsule, and are known as diffuse or infiltrating fibroids. 
They are found in the tube, the uterine horn, and occasionally in 
the posterior wall of the uterus. 

Gebhard gives the following varieties : 

1. A hard form in which the muscle tissue predominates over 
the glandular elements. 

2. A cystic tumor with many large spaces. 

3. A soft form in which the glandular elements predominate 
over the fibrous or muscular. 

4. A soft form with widened blood spaces — telangiectatic or 
angiomatous adenomyoma. 

In the growths are often seen small ducts communicating with a 
single large one as the teeth of a comb are joined to its back. These 
ducts are embryonic inclusions of the ducts of the Wolffian body and 
the " uriniere." They may distend into cysts compressing the sur- 
rounding connective tissue. The contents of the cyst are clear and 
serous, occasionally colored by pigment. 

Recklinghausen speaks of pseudoglomeruli in describing eleva- 
tions attached to the cyst wall by a broad base. 

Pick described a submucous adenomyoma averaging 55 grammes. 



THE DIAGNOSIS OF FIBBOMYOMA OF THE UTEBUS. 265 

Cullen reported to the Johns Hopkins Society an adenomyorna of 
the round ligament. 

DEGENERATION OF FIBROIDS 

The various forms of degeneration of fibroids are not only of 
pathological interest, but their recognition is of the greatest clinical 
importance. Nobel estimates that serious complications arise in 
fibroids in about one-third of all cases. Of these complications 
the various forms of degeneration constitute a large proportion. 



Fig. 139. 




Fibrocystic myoma uteri. The interior of the tumor shows the fibrocystic change. (Dudley.) 



1. Atrophy. We are familiar with a physiological atrophy of 
fibroids following the climacteric. A similar change takes place 
in event of an artificially induced menopause by the removal of the 
ovaries. In pedunculated tumors the blood supply is limited, and 
as a result atrophy may follow. According to Shroeder, this 
atrophy consists of a fatty degeneration. It is more probably a 



266 SPECIAL DIAGNOSIS. 

simple atrophy in which the muscle cells diminish in size and in 
number. In this manner large tumors may wholly disappear. 

2. Calcareous degeneration may occur in fibroids of all sizes and 
locations. The calcareous deposits are found in the connective 
tissue, often leaving the muscle fibres isolated and incrusted. 

Fig. HO. 



Multiple myomata. (Dudley.) 

Gebhard gives the following analysis of the deposit : 

Calc. carb 49.0 

Calc. phosph. 29.0 

Calc. sulph. 13.0 

Calc. lithat 0.5 

Organic substances 0.4 



THE DIAGNOSIS OF FIBBOMYOMA OF THE UTEBUS. 267 

Petrified fibroids are known as " womb stones." It is possible 
for such stones to be severed from the uterus and lie free in the 
peritoneal cavity, or, if submucous, to be either retained in the 
uterus or expelled. Womb stones were described by Hippocrates. 
Everett reported one weighing 2.04 kg. 

3. Fatty degeneration of fibroids following pregnancy is of 
common occurrence. The tumor is soft and of a mottled, yellow 
tint. Fat droplets are seen in the muscle fibres. 



Fig. 141. 




A pedunculated subperitoneal fibroid lies above the promontory of the sacrum and is too 
large to fall into the pelvis. It has drawn the uterus and vagina upward. 



4. Myxomatous degeneration of fibroids is a circumscribed degen- 
eration of the connective tissue. Rarely is there a diffuse involve- 
ment of the tumor. Before cutting into the tumor it may appear 
cystic. On cross-section one or more areas of degeneration are 
seen. The myxomatous material is glairy and translucent, contain- 



268 SPECIAL DIAGNOSIS. 

ing opaque particles and a fibrillar or fibrous network. By absorp- 
tion of the myxomatous material cystic spaces are formed. 

5. Suppuration and gangrene of fibroids is a grave condition 
demanding immediate surgical interference. The usual cause is 
puerperal infection. Subserous fibroids may be infected through 
the bowel. Twisting of the pedicle of a fibroid may result in 
gangrene. 

6. Amyloid degeneration of a fibroid is described by Stratz. 

7. Telangiectatic fibroids are of rare occurrence. They are 
formed either from a dilatation of the lymph or blood spaces. The 
tumor is soft and may fluctuate. 

8. Sarcomatous degeneration of fibroids will be discussed in the 
chapter on Sarcoma of the Uterus. 

9. Cancerous degeneration is an unusual form. The epithelial 
elements are derived from the overlying mucosa in submucous and 
interstitial growths or from the glandular elements of an adeno- 
fibroma. But two cases are recorded in which the cancer began in 
the substance of the fibroid. 

Enchondroma and osteoma are occasionally mixed with a fibroma. 

CHANGES IN THE ENDOMETRIUM, MYOMETRIUM, TUBES, 
AND OVARIES 

The endometrium undergoes hyperplastic changes under the irri- 
tating influence of the fibroid. Hence it is that these changes are 
almost invariably found in submucous, usually in interstitial, and 
seldom in subperitoneal fibroids. There is hypertrophy and hyper- 
plasia of the elements forming the endometrium. In large fibroids 
bulging into the uterine cavity there may be pressure atrophy of 
the mucosa. When protruding into the vagina the endometrium 
may be transformed into many layers of stratified epithelium and 
decubitus ulcers may form upon the surface. 

The myometrium becomes hypertrophied. This is particularly 
true of submucous and interstitial growths. The hypertrophy is 
proportionate to the size and number of the tumors. 

The tubes and ovaries share in the hypertrophy to a limited 
extent. It is estimated that the tubes are diseased in 10 per cent, 
of all cases. 

Clinical Characteristics of Fibroids. 1. Shape. A fibroid 
grows concentrically, and hence is usually round. The firm, sub- 



THE DIAGNOSIS OF FIBBOMYOMA OF THE UTERUS. 269 

serous tumors, which from their location are less influenced by the 
uterus, are round or oval. Submucous fibroids of softer consistency 
are moulded by the uterus. When forced through the cervix they 
become elongated and even hour-glass shaped. Interstitial fibroids 
confined within the uterine wall are round. 

2. Mobility. Only pedunculated submucous and subserous 
fibroids move independently of the uterus. Broad ligament fibroids 
are restricted in their movements. Fixation by adhesions and by 
incarceration restricts the movements of the tumor and the uterus 
to which it is attached. 

3. Consistency. The consistency of a fibroid varies from a stone- 
like hardness to the softness of a pregnant uterus, and may even 
appear to fluctuate. This variation in consistency is largely to be 
accounted for by the relative proportions of fibrous and mus- 
cular tissue comprising the growth. The more fibrous tissue the 
harder the growth. The forms of degeneration causing a hardening 
of the growth are atrophy (so-called fibroid degeneration), calcareous, 
cartilaginous, and osteomatous degeneration ; those causing a soften- 
ing of the fibroid are fatty, myxomatous, cystic, oedematous, 
purulent, gangrenous, telangiectatic, sarcomatous, and cancerous 
degeneration. During pregnancy the tumor softens and grows 
rapidly ; after pregnancy it becomes smaller and firmer. 

During the period of menstrual congestion the growth increases 
slightly in size and is more elastic. 

4. Rate of Growth. The softer and more vascular the tumor the 
more rapid its growth. It is important to observe the rate of 
growth in distinguishing a growing fibroid from a pregnant uterus 
and in determining malignant degeneration. 

Clinical Diagnosis of Uterine Fibroids. The diagnosis of 
uterine fibroids rests largely upon the local findings. Symptoms 
at best are only suggestive of their possible presence. 

Subjective Signs. Two general groups of symptoms are to be 
considered : those due to hemorrhage, and those due to pressure 
and traction made by the growing tumor. 

1. Hemorrhage in the form of an increase of the menstrual 
flow is usually the first event that attracts the attention of the 
patient. As time goes on the loss of blood may seriously under- 
mine the patient's health, and has been known to cause death. 
There may be no intermission, or intervals of variable length may 
be interrupted by profuse and even alarming hemorrhages. It is 



270. SPECIAL DIAGNOSIS. 

seldom that the loss of blood is distinctly and exclusively inter- 
menstrual. The blood comes from the endometrium, rarely from 
the fibroid. The tumor acts as a foreign body irritating the 
endometrium. Hence it is that hemorrhage occurs almost invari- 
ably in submucous fibroids, to a lesser extent in interstitial, and 
seldom in subperitoneal fibroids. It is possible for a subperitoneal 
growth to interfere with the circulation in the uterus and indirectly 
cause hemorrhage. Mental excitement, physical exertion, and 
instrumental and digital examinations excite hemorrhage. The 
blood is often expelled in clots. This clotting is partly the result 
of obstruction to the outflow of blood by the tumor and by 
displacements of the uterus. 

2. Pressure and traction made by the growing tumor upon sur- 
rounding structures are later developments than hemorrhage, and 
are not usually manifest until the tumor has attained considerable 
size. Subperitoneal growths are most likely to produce these 
symptoms. A variety of symptoms arises from direct pressure 
and traction. Pain is caused by pressure of the growing uterus 
and tumor upon the various structures in the pelvis. A fibroid 
incarcerated in the small pelvis may early cause pain even to 
an intolerable degree. Intraligamentary fibroids no larger than a 
man's fist may occasion distressing pain. On the other hand, large, 
freely movable fibroids occupying the abdominal cavity may cause 
no pain. 

The pain is referred to the lumbar and sacral region, to the 
shoulders, breasts, and thighs, and rarely to the cervical and inter- 
scapular regions. 

In submucous growths the pain may be due to intermittent 
uterine contractions excited by the growing fibroid. Such pains are 
usually colicky, and are most severe during the period of menstrual 
congestion. If, as sometimes happens, the outflow of menstrual 
blood is obstructed, there will be a so-called obstructive dysmenor- 
rhoea due to intra-uterine tension and to an effort on the part of the 
uterus to expel the blood clots. Pain, in most cases of uterine 
fibroids, first manifests itself at the menstrual period when the 
uterus and tumor are swollen and tender from congestion. 

The " birth of a fibroid " — i e., the expulsion of a submucous 
fibroid — is associated with labor-like pains of astonishing severity. 
After the flow is well started the pain may be relieved. The more 
abundant the blood supply to the tumor the greater will be the 



THE DIAGNOSIS OF FIBROMYOMA OF THE UTERUS. 271 

menstrual swelling. Acute pain on external pressure may be ex- 
perienced in the menstrual period from irritation of the perito- 
neum. Mechanical irritation of the peritoneum caused by the 
movable tumor may set up a localized peritonitis, and this in turn 
adds to the pain and discomfort. 

Pressure of a fibroid upon the abdominal and thoracic viscera 
gives rise to a variety of symptoms. Pressure upon the bladder 
causes vesical tenesmus, frequent urination, and catarrh of the 
bladder. A small subperitoneal fibroid attached to the anterior 
surface of the uterus may cause serious disturbance in the bladder. 
The uterus may be compressed, leading to hydronephrosis, pyo- 
nephrosis, and uraemia. The urethra is rarely pressed upon by 
the tumor, though the bladder may be elevated and the urethra 
stretched and distorted. 

Pressure upon the rectum may cause constipation, rectal tenes- 
mus, a sense of fulness and pressure in the rectum, and a catarrhal 
discharge. 

Pressure upon the veins of the pelvis may cause oedema and 
varicosities of the lower extremities. 

When the tumor is large enough to fill the abdominal cavity, 
pressure upon the bowel and stomach will interfere with digestion, 
and pressure upon the diaphragm will hinder its excursions and 
thereby interfere with the functions of the heart and lungs. Great 
intra-abdominal pressure caused by large fibroids undoubtedly 
embarrasses the functions of the kidneys. 

Torsion of the pedicle of a fibroid is possible ; furthermore, it is 
possible for a fibroid to cause a torsion of the uterus (see Fig. 80). 
In this manner a fibroid may be completely twisted from the 
uterus. Such an event must necessarily be followed by gangrene 
of the tumor, unless an adequate blood supply is conveyed by the 
adhesions. Immediately upon the twisting of the pedicle there is 
severe abdominal pain, together with a sudden increase in the size 
of the fibroid. Vomiting and collapse follow — the clinical picture 
being not unlike that of a strangulated hernia, or the twisted pedicle 
of an ovarian cyst. When the torsion is partial or slow in its 
development, the symptoms will be less pronounced. When a 
fibroid becomes infectious or gangrenous, the event will be ushered 
in by a rise in temperature, chills, and pain. The tumor will be 
tender to pressure and increased in size. When submucous, a 
stinking discharge will come from the uterus. When a subperi- 



272 SPECIAL DIAGNOSIS. 

toneal fibroid becomes gangrenous, the symptoms are less charac- 
teristic. Pain may be absent. Rise of temperature and tenderness 
on pressure are all but constant symptoms. The usual signs of 
peritonitis supervene when the affection spreads to the peritoneum. 

Calcareous degeneration gives rise to no symptoms suggestive of 
the condition. There is but one sign upon which a positive diag- 
nosis can be based, and that is the expulsion of part or all of the 
growth in which the calcareous deposits are found. This seldom 
occurs, because submucous fibroids rarely calcify and are seldom 
expelled. 

Objective Signs. It is evident that a positive diagnosis cannot 
be made from the above subjective signs. From them we can only 
conclude that there is a swelling of some sort causing the pressure 
symptoms. A physical examination is indispensable in making a 
diagnosis. 

The diagnosis is based upon the recognition of a tumor connected 
with the uterus and having certain fairly definite characteristics. The 
recognition of a fibroid of the uterus is ordinarily easy, but may be 
rendered difficult by various circumstances. In order that a diag- 
nosis of fibroids be made the tumor must either be seen or outlined 
by the examining hands. Many conditions may exist to render 
such a procedure impossible, and at such times the diagnosis must 
be reserved until an exploratory incision has been made. 

Small interstitial fibroids can only be suspected from the size and 
irregular consistency of the uterus. In large, interstitial fibroids 
there is difficulty in outlining the uterus apart from the tumor. 
The sound passed into the uterine cavity will locate the uterus, and 
when combined with a conjoined examination it should be possible 
to determine the existence of a fibroid and its position relative to 
the uterus. In outlining the respective positions of the uterus and 
tumor it is important to recognize their difference in form and 
consistency. 

A subperitoneal fibroid is ordinarily identified by a conjoined 
examination. When the tumor is large abdominal palpation may 
alone be sufficient. The form, consistency, and relation to the 
uterus may suffice for a diagnosis. Much dependency may be 
placed upon the firmer consistency of the tumor as compared with 
the uterus, and particularly is this of importance in differentiating 
a fibroid from a pregnant uterus. 

As with interstitial fibroids, great difficulty may be experienced 



THE DIAGNOSIS OF FIBBOMYOMA OF THE UTEBUS. 273 

in outlining a large sessile subperitoneal fibroid from the uterus. 
The irregular outline, the firmer consistency, the groove or angle 
which may mark the connection between tumor and uterus are 
points which, together with the use of the sound, should suffice for 
a diagnosis in the majority of cases. Greater difficulty is experienced 
with multiple subperitoneal fibroids. 

Intraligamentary or broad ligament fibroids are recognized by 
their point of attachment along the side of the uterus, by their 
lessened mobility, by the course of the adnexse which run over the 
tumor, and by the crowding of the uterus to the side of the pelvis. 
The growth may spring from the supravaginal portion of the cervix 
or from the side of the uterine body. 

Plate VI. represents a single large subperitoneal fibroid causing 
a rounded protuberance of the abdomen. Plate VII. represents 
an abdomen distended by multiple subperitoneal fibroids, in which 
the irregularities are plainly visible. 

Submucous fibroids can only be diagnosed with certainty when 
they are seen protruding through the cervix, or when palpated 
through the cervical canal. The hemorrhage and uterine colic will 
suggest the possible presence of a submucous fibroid, but the diag- 
nosis must be kept in reserve for a physical examination. Within 
the uterine cavity the finger detects a firm, rounded tumor con- 
nected with the uterus by a broad base or pedicle. The fibroid may 
be felt as a circumscribed bulging tumor upon the mucosa. With 
the sound or curette similar observations may be made, though 
with less certainty. 

Fibroids of the cervix are not difficult to diagnose when attached 
to the vaginal portion. Their attachment to the cervix can be 
demonstrated by inspection or by the finger and sound. Small 
interstitial fibroids of the cervix are recognized by the firm, rounded, 
and sharply circumscribed area of resistance which characterizes 
their presence. 

The use of the sound in the diagnosis of uterine fibroids is not to 
be underestimated, yet its application should be restricted to the 
cases in which a conjoined examination fails to clear up the diag- 
nosis. Aside from the danger of infection, there is the added risk 
of perforating the uterus at a point possibly thinned by the tumor. 

Great difficulty may be experienced in the passage of the sound. 
The tumor may be impinged upon and give the impression that 
the depth of the uterus is short in contrast to the usual lengthening 

18 



274 



SPECIAL DIAGNOSIS. 

Fig. 142. 






M 

It is possible to locate a fibroid in relation to tbe uterus by palpating the uterine appendages 

and round ligaments. 
I. The fibroid is subperitoneal and sits upon the fundus, hence the appendages and round 
ligaments are not disturbed in their relative positions. II. The fibroid is subperitoneal and 
sits upon the posterior wall of the uterus, and extends backward and to the left. The ap- 
pendages and round ligaments are not disturbed in their relative positions. III. The fibroid 
is interstitial and evenly distends the uterus, hence the appendages and round ligaments are 
separated on the same plane. IV. The fibroid is interstitial and lies in the fundus and right 
cornua. The right tube and round ligaments are elevated and dislocated outward. 



THE DIAGNOSIS OF FIBROMYOMA OF THE UTERUS. 275 

of the uterine cavity as found in the presence of submucous and 
interstitial fibroids. The shape of the uterine cavity is also to be 
noted by the sound. It may be encroached upon and greatly dis- 
torted, so much so that the sound cannot be passed to the fundus. 

Palpation of the Adnexae and Round Ligaments. In favorable 
cases the tubes and round ligaments can be palpated in a conjoined 
examination. It is observed that their location and point of attach- 
ment are altered by the tumor, and it is sometimes possible to 
locate the tumor in its relation to the uterus by observing the posi- 
tion of the adnexa and round ligaments. 

Where the uterus is small and a larger fibroid sits upon the 
fundus the tumor may be mistaken for the uterus. The attach- 
ment of the tubes and round ligaments when determined will 
indicate the position of the uterus apart from the tumor. The 
sound will confirm the findings. 

A submucous or interstitial growth evenly distending the uterus 
will separate the attachments of the round ligaments and adnexae. 
An interstitial fibroid of the anterior wall will separate the round 
ligaments and tubes, and if to one side of the median line the cor- 
responding tube and round ligament will be elevated above the 
other. An interstitial fibroid on the posterior surface of the 
uterus will tend to approximate the appendages. 

If the fibroid is on the side of the uterus the corresponding round 
ligament and tube may be elevated. Fig. 142 illustrates these facts. 

The diagnosis of malignant degeneration of a fibroid is discussed 
in the chapter on Sarcoma of the Uterus. 

Differential Diagnosis. Fibroids of the uterus commonly ap- 
pear during the period of sexual maturity when pregnancy, inflam- 
matory lesions, and displacements are likely to arise, and it is for 
this reason that the differential diagnosis is of such importance. 

Interstitial Fibroids. Chronic Metritis. 

1. Irregular enlargement of the uterus unless 1. Uniform enlargement. 

tumors are small. 

2. Variable consistency. 2. Uniform, firm consistency. 

3. Not tender to pressure. 3. Commonly tender to pressure. 

4. Uterus freely movable. 4. Uterus usually restricted in its movements. 

5. No history of infection. 5. History of infection. 

6. Symptoms of uterine catarrh not common. 6. Symptoms of uterine catarrh generally 

present. 

When the fibroids are multiple and small it may be impossible 
to distinguish such a lesion from chronic metritis. The clinical 
history cannot be relied upon. 



276 



SPECIAL DIAGNOSIS. 



Uterine Fibroid. 

1. Usual signs of pregnancy absent. 1. 

2. Tumor of firm consistency, rarely soft. 2. 

3. Intermittent uterine contractions absent. 3. 

4. Irregular and asymmetrical growth. 4. 

5. Slow growth. 5. 

6. Cervix firm, not patulous. 6. 

7. Positive signs of pregnancy absent. 7. 



Uterine Pregnancy. 
Present. 
Soft and elastic. 
Present. 

Rate of growth regular and symmetrical. 
More rapid growth. 
Cervix soft and patulous. 
One or more present, i. e.: 

a. Foetal heart tones. 

b. Foetal bruit. 

c. Active foetal movements. 

d. Palpation of foetal parts. 

e. Ballottement. 



Fig. 143. 




Myoma complicated by pregnancy. Complete hysteromyomectomy ; recovery. (Dudley.) 

Of greatest importance in the differential diagnosis of fibroids 
from early pregnancy is the uniform rapid growth of the pregnant 



THE DIAGNOSIS OF FIBROMYOMA OF THE UTERUS. 277 

uterus, the intermittent uterine contractions and characteristic 
doughy consistency. Later, when positive signs of pregnancy are 
elicited, there should be no mistaking the fact of pregnancy. 

A large, soft, interstitial fibroid may evenly distend the uterus. 
Its soft consistency, regular outline, and rapid growth may suggest 
the presence of a pregnant uterus. In addition to the above find- 
ings, there may be nausea and vomiting, enlargement of the breasts, 
softening and discoloration of the vaginal portion of the cervix. 
With such a condition it may be impossible to make a diagnosis 
from early pregnancy. Keeping the case under observation for a 
few weeks, it will be noted that the growth is slower than in preg- 
nancy, that there are no intermittent contractions and that none of 
the positive signs of pregnancy develop. 

But the diagnosis of fibroids complicated by pregnancy is often 
a difficult problem. Small subperitoneal fibroids may be mistaken 
for part of the foetus. Under the influence of pregnancy a fibroid 
grows rapidly and becomes soft. It is, however, unusual for the 
growth to become as soft as the pregnant uterus, so by the circum- 
scribed area of firmer resistance the fibroid is outlined apart from 
the pregnant uterus. If the examination is made during a uterine 
contraction this difference in consistency between the uterus and 
fibroid is not evident. Repeated and prolonged examinations may 
be required. 

No tumor other than a pregnant uterus displays these intermittent 
contractions. 

When through a morbid state of the contained foetus the uterus 
remains in a state of tonic contraction, the discovery of an inter- 
stitial fibroid may be impossible. When in doubt as to the diag- 
nosis, and the condition of the patient does not demand immediate 
interference, it is always advisable to await developments and make 
examinations at frequent intervals. 

Subserous Uterine Fibroids. Hematoma and Hematocele. 

1. No history of recent pregnancy. 1. Frequently history of pregnancy. 

2. Slow, continued development. 2. Sudden development. 

3. Consistency firm, rarely soft. 3. Consistency at first is fluctuating, later is 

doughy. 

4. Sharply circumscribed tumor. 4. Ill-defined tumor. 

5. Exploratory puncture negative. 5. Exploratory puncture— blood obtained. 

Gangrene with a fatal termination has been known to follow an 
exploratory puncture of a fibroid. 

For the differential diagnosis of uterine fibroids from displace- 



278 SPECIAL DIAGNOSIS. 

ments of the uterus, carcinoma, sarcoma, tubal and ovarian swell- 
ings, and pelvic exudates, see respective chapters on these subjects. 
A case in the experience of the author, and another recently 
observed by Bayard Holmes, presented a soft subperitoneal fibroid 
near the horn of a pregnant uterus which was thought to be an 
ectopic gestation. In both cases the pregnancy was early ; the 
fibroids were not discovered until the pregnant uterus began to 
rise out of the pelvis, bringing the tumor with it. 



CHAPTER XXVI. 

THE DIAGNOSIS OF CAECINOMA OF THE UTERUS. 

Topographical Classification. Carcinoma may arise from any 
portion of the uterine mucosa, both within the uterus and covering 
the vaginal portion of the cervix. The classification proposed by 
Huge and Veit is as follows : 

1. Carcinoma of the vaginal portion of the cervix, including the 
vaginal surface of the cervix from the external os to the vault of the 
vagina. 

2. Carcinoma of the cervix, including the mucosa of the cervical 
canal. 

3. Carcinoma of the body of the uterus, including the mucosa from 
the internal os to the horns of the uterus. 

It will be observed that the location of the new-growth is not 
only of pathological interest, but has much to do with the manner 
of diagnosis, the clinical manifestations, prognosis, and treatment. 

Etiology. We find carcinoma of the uterus commonly appearing 
about the time of the menopause. Carcinoma of the vaginal portion 
more often makes its appearance immediately preceding the meno- 
pause, and carcinoma of the body usually appears a few months or 
years later. The earliest recorded case appeared at eight years of 
age. I have lately observed a case of carcinoma of the vaginal 
portion in a woman, aged ninety-three years. 

Heredity, while playing an important role, is of less importance 
as an etiological factor than was formerly believed. 

It has been said that the negress is particularly exempt from 
carcinoma of the uterus. Later observations tend to disprove this 
view, indicating that the negress is little less susceptible than the 
white woman. 

Childbearing appears to have an important relation to the develop- 
ment of carcinoma of the vaginal portion. The author has seen but 
one carcinoma of the vaginal portion in a nullipara whose cervix has 
never been dilated. The patient was forty-three years of age. 
The uterus was removed by Dr. D. W. Graham, of the Chicago 
Presbyterian Hospital. The great rarity of carcinoma of the cervix 



280 SPECIAL DIAGNOSIS. 

in nullipara speaks for the influence of trauma as a factor in the 
development of cancer. Carcinoma of the body of the uterus is 
said to be more frequent in nulliparae. 

There can be no question that the inflammatory lesions of the 
uterus (endometritis and erosions) are not seldom the starting-points 
of carcinoma ; but that scars in the cervix are such is justly ques- 
tioned. While fibroids and carcinoma are often associated in the 
uterus, it is not probable that the one is in any way dependent 
upon the other for its existence. 

Carcinoma of the uterus is found more frequently in the lower 
orders of society. These classes are more susceptible to and 
neglectful of infections and traumatisms. 

Fig. 144. 




Carcinoma of the cervix involving the parenchyma of the vaginal portion. (Ruge and Veit.) 

Cohnheim's theory of cell inclusion is not supported by observa- 
tions made upon the carcinomatous uterus. 

Leopold concludes from a series of experiments that pure cultures 
of the blastomycetes may be found in fresh carcinoma of the ovary. 
He injected a pure culture into the testicle of a rat. The animal 
died, and on the peritoneum were found nodules in which were 
similar blastomycetic organisms. Leopold infers that this organism 
may be the cause of carcinoma in man. 

The frequency of carcinoma of the uterus is variously stated. 
Welsh found that in 31 ? 482 cases of carcinoma 29.5 per cent, were of 



THE DIAGNOSIS OF CARCINOMA OF THE UTERUS. 281 



the uterus. In point of frequency the uterus takes second rank to 
the stomach as a primary seat of carcinoma. There can be no doubt 
but carcinoma is on the increase, though it is only fair to admit 
that the perfected means of diagnosis account in large part for the 
statistics. 

Anatomical Diagnosis. I. Carcinoma of the vaginal portion of the 
cervix may tend to grow superficially into the vagina, forming a 
polypoid or cauliflower growth ; or it may deeply infiltrate the 
cervix. 

Fig. 145. 




Carcinoma of the cervix uteri ; cavity of cervix excavated. (Ruge and Veit.) 

. 1. Cauliflower carcinoma of the vaginal portion of the cervix 
is seen as a sessile or pedunculated growth arising from one or both 
lips of the cervix. It varies in size up to the complete filling of 
the vagina. The surface is generally covered with a slimy, gan- 
grenous deposit. The whole mass bleeds readily to the touch and 
is friable. The surface is uneven, nodular, polypoid, or villous. 

2. Infiltrating carcinoma of the vaginal portion of 
the cervix appears in the early stage as an irregular thickening 
and hardening of the cervix. The anterior lip is most often first 
involved. 



282 SPECIAL DIAGNOSIS. 

C alien distinguishes three stages according to the degree of infil- 
tration and disintegration of the cervix. While this classification 
is purely arbitrary, it will be found convenient for purposes of 
description. 

Stage 1 . This is the stage of infiltration in the absence of disinte- 
gration. The surface is hard, friable, and uneven. The color 
of the surface is glistening, bluish- white. Cross-sections of the 
growth show a gray or yellowish-gray surface, often cutting like 
cartilage. Fibrous striations are seen to course through the struc- 
ture, isolating nests of friable homogeneous tissue, the so-called 
cancer nests. By squeezing the surface, these nests may be emptied 
of their cell contents, leaving small, shallow depressions. Such 
nests are not to be confused with Nabothian follicles filled with 
inspissated mucus. The two may be found in the same section. 
Unfortunately, cancer of the vaginal portion is seldom observed at 
this stage, because of the mild symptoms which prevail. Not infre- 
quently there is an entire absence of symptoms. While impossible 
to say without an anatomical dissection, it is probable that the 
growth is still confined to the cervix. Yet it must be borne in 
mind that not only regional but general dissemination of the car- 
cinoma may occur at this stage. 

Stage 2. This is the Stage of Moderate Disintegration. The 
carcinomatous tissue has partially disintegrated, leaving a depression 
with irregular, hard, elevated margins. The base of the ulcer is 
uneven, and covered with a stinking slough of a grayish-yellow or 
gangrenous character. Upon handling the affected tissue bleeds 
freely and is friable. In this stage the growth is rarely confined 
to the cervix. More than half the vaginal tissue may be lost. 

Stage 3. This is the Stage of Complete Disintegration of the Vaginal 
Portion of the Cervix. In the vault of the vagina is a sloughing, 
stinking, ragged crater. No cervix is to be seen or felt. The 
vaginal walls are invaded and form the margins of the crater. The 
paravaginal connective tissue, broad ligaments, and uterosacral 
ligaments are infiltrated. The growth is slow to pass beyond the 
internal os into the cavity of the uterus, but may extend to the 
fundus. Isolated cancerous nodules may lie in distant portions of 
the vaginal wall. Contact growths may develop upon opposing 
surfaces. The bladder is involved late, and the rectum still later, 
as a rule. Only in the very late stage is the peritoneum invaded. 
The iliac glands are the first of the lymphatics to be invaded, but 



THE DIAGNOSIS OF CARCINOMA OF THE UTERUS. 283 

these are late in being affected and may entirely escape. Metastatic 
growths in distant parts of the body are seldom observed. 

II. Carcinoma of the Cervix. Carcinoma of the cervix takes its 
origin from the epithelium of the cervical mucosa confined within 
the boundaries of the external os below and the internal os above. 



Fig. 146. 




Lymphatics of uterus and upper third of vagina, and iliac and lumbar glands. (Russell.) 

The carcinomatous growth may involve all or a part of the mucosa. 
It may assume a nodular or cauliflower appearance, or may infil- 
trate the underlying tissue. The entire cervix may be infiltrated 
and will eventually disintegrate, leaving a crater-like structure 
with a thin shell. The lips of the cervix may close in over the 
growth, hiding it from view. It is seldom, if ever, that the lips 



284 SPECIAL DIAGNOSIS. 

are disintegrated, but in the late stages they are infiltrated and 
glazed. On cross-section the carcinomatous mass is cartilaginous, 
yellowish-white, and glistening. The advancing border is irregular 
and blends into the normal tissue. The body of the uterus and 
vagina may be invaded either by direct extension or by metastasis. 

The paravaginal connective tissue is invaded comparatively early. 
It is unusual to observe a case before the broad ligaments are 
involved, hence the prognosis is grave. 

The peritoneal cavity is invaded late. The tubes, ovaries, 
bladder, and rectum are seldom attacked. The iliacs are the first of 
the lymphatic glands to be invaded. Metastasis to distant organs 
seldom occurs. Winter found the iliac glands involved in 22 per 
cent, of cases of cancer of the cervix. He found four cases of 
advanced cancer of the cervix without involvement of these glands. 
Emil Reese has made extended observations on the involvement of 
the lymphatic glands in cancer of the cervix. He has shown that 
the glands of the pelvis are often cancerous when no larger than 
normal. Again, they are sometimes enlarged from a hyperplasia, 
the result of an ulcerative process in the growth. Extensive 
glandular involvement contraindicates all but palliative treatment. 

III. Carcinoma of the Body of the Uterus. Carcinoma may arise 
from any part of the mucosa of the uterine body, either as a circum- 
scribed or as a diffuse growth. The surface is never smooth. It 
begins as a shaggy growth studded with delicate villosities, which 
may later enlarge and coalesce into polyps or form twig-like pro- 
cesses with numerous offshoots. In late and far-advanced cases the 
growth presents the appearance of grain tissue. The entire uterine 
cavity may be filled with the cancerous growth. The musculature 
of the uterus is very slowly invaded, and it is for this reason that 
cancer of the body of the uterus is regarded as relatively benign. 

On cross-section the invading carcinomatous tissue, with its pale, 
homogeneous and glistening appearance, is in contrast to the mus- 
culature. The advancing border is irregular. When the serous 
covering of the uterus is invaded small grayish-yellow nodules 
are seen beneath the serosa. The growth is usually late in slough- 
ing. 

Extension from the body of the uterus is extremely slow. The 
internal os is rarely trespassed ; the broad ligaments are not infil- 
trated until late. The peritoneum may be directly invaded, but 
this is late, if at all. The bladder, rectum, tubes and ovaries com- 



THE DIAGNOSIS OF CARCINOMA OF THE UTERUS. 285 

nionly escape invasion. Metastasis to distant parts of the body is 
late, and may never occur. Kroemer believes we find metastasis 
more common in carcinoma of the uterine body than of any other 
part of the uterus. 

As to the frequency of carcinoma of the body of the uterus, Schatz 
says that it occurs in 2.5 per cent., and Schauta says in 13.8 per 
cent., of all carcinomata of the uterus. 

Clinical Diagnosis. A work of this character could do no 
greater service than to emphasize the importance of an early diag- 
nosis in carcinoma of the uterus, and to point out the methods of 
making such a diagnosis. 

No departure from the normal menstrual flow should be regarded 
as trivia! in advanced years of life. We are not to be contented with 
the supposition that it is a phenomenon of the change of life — too 
many lives have been sacrificed by such inferences. 

It is the family physician, not the specialist, who first sees these 
cases, and it is to him we must look for the early recognition of the 
danger, if not for a positive diagnosis. The practitioner must be 
firm in his demand for a local examination. Ignorance, sloth, 
prejudice, and false modesty are to be discountenanced. Where the 
physician, after a searching examination into the cause of the hem- 
orrhage, fails to satisfy himself, he should appeal to the specialist, 
whose services at this time are of greater value than in the treat- 
ment of the case, for the reason that it takes greater skill to make 
a diagnosis in these doubtful cases than it does to remove the uterus 
after the diagnosis is made. Since the early recognition of carcinoma 
of the uterus rests upon the microscopic examination of scrapings 
and excised pieces of the suspected portion, it is self-evident that 
only those especially trained in the work are competent to make 
such a diagnosis. 

Symptoms in the early stage, while there is yet time to interfere, 
are at best only suggestive of the lesion. 

Hemorrhage is usually the first of the symptoms to appear. It 
is at first excited by some physical exertion, such as straining at 
stool, lifting burdens, and sexual intercourse. All departures from 
the normal menstrual flow, or all losses of blood not in relation to 
the menstrual period, call for a careful examination. The older the 
individual the greater the probability of carcinoma. In carcinoma 
the loss of blood is at first slight ; rarely does it begin with a pro- 
fuse flow. A watery discharge may precede the flow of blood weeks 



286 SPECIAL DIAGNOSIS. 

and months, and is highly suggestive of carcinoma. The patient 
becomes anaemic, and strength fails as a result of the hemor- 
rhage. 

Leucorrhoea is almost invariably present, at first in the form of a 
watery, odorless discharge, later as a thicker white or yellowish 
fluid, and, finally, of a stinking, dirty, bloody discharge. Such a 
discharge can only be regarded with suspicion ; it is in no sense 
pathognomonic. Sloughing fibroids, decomposing placental tissue, 
and senile endometritis may cause a similar discharge. As in 
hemorrhage, so with such a leucorrhoea, a careful examination is 
imperative. 

Pain is seldom an early manifestation of carcinoma of the uterus, 
and is less reliable as a guide to diagnosis than is hemorrhage or leu- 
corrhoea. Not infrequently the growth is far advanced before pain 
is experienced. In such cases the pain begins when the growth has 
extended beyond the uterus. Pain and hemorrhage are often in 
inverse proportion. The pain is aggravated by the congestion, and 
when the flow of blood is considerable the congestion is relieved 
and this in turn lessens the pain. 

Miscellaneous symptoms arise from extension to the surrounding 
structures. The bowels become constipated, and defecation is 
painful from the pressure of the growth. As the rectum is invaded 
a mucous or mucohemorrhagic discharge comes from the rectum ; 
finally, a rectovaginal fistula develops. Invasion of the bladder 
causes frequent urination, irritability of the bladder, bloody urine, 
and, finally, a vesicovaginal fistula. 

When the cellular tissue of the pelvis is involved there may be 
pain referred to the groin, thighs, and legs. CEdema of the legs, 
often of one side, may result from an involvement of the veins and 
lymphatics of the pelvis. In almost every case of advanced carci- 
noma of the uterus the kidneys are involved and ursemic symptoms 
may be manifest. 

Cachexia develops in the advanced stage, though it may be sur- 
prisingly late in making its appearance. The above symptoms are 
responsible for the cachexia. 

• I. The diagnosis of carcinoma of the vaginal portion of the cervix can 
be made with greater ease and certainty than in any other portion 
of the uterus, because of the greater accessibility to touch and sight. 

In the infiltrating form with an overlying covering of mucous 
membrane the diagnosis is difficult without the aid of the micro- 



THE DIAGNOSIS OF CABCIX03IA OF THE UTERUS. 287 

scope. The broadening of the cervix, the irregular nodular surface, 
the cartilaginous consistency, and the glistening, bluish color are 
not sufficiently characteristic. The friability and tendency to bleed 
when grasped by a tenaculum or when the finger-nail is gouged 
into it, are regarded by many of large clinical experience as charac- 
teristic of cancer, and altogether reliable in making a diagnosis. 
While much reliance can be placed on these signs, the microscopic 
examination of an excised piece of the suspected portion must be 
regarded as the conclusive test, without which a positive diagnosis 
is often impossible. When ulceration follows the diagnosis is made 
with greater ease. The hard, glistening, irregularly elevated 
border, together with the friability and tendency to bleed when 
handled, leaves little doubt as to the carcinomatous nature. There 
is then little need for the microscope to confirm the diagnosis. 

A cauliflower growth is more readily recognized as malignant 
than the infiltrating form, yet papillary erosion must be excluded, 
and to make a careful differentiation the microscope will often be 
found indispensable. The greater the clinical experience of the 
examiner the larger will be the percentage of cases in which the 
diagnosis can be made from the clinical signs and symptoms. 
But there will remain a certain number in which the diagnosis can 
only be made by a microscopic examination of an excised piece of 
the suspected portion. (See Microscopic Diagnosis, page 289.) 

II. The diagnosis of carcinoma of the cervix is rarely made early, 
because the growth is not accessible to the sense of touch or sight, 
hidden as it is above the external os. Indeed, the growth may go 
on to an advanced stage, destroying the mucous membrane and 
underlying connective tissue, and yet be unsuspected. Where the 
destruction of tissue is seen through a vaginal speculum the diag- 
nosis is not difficult, but this is not possible in the early stage when 
a radical cure is assured. 

When the cervix is artificially dilated bleeding is profuse and 
tearing can scarcely be avoided. The finger or curette gouges out 
friable masses. The friability and bleeding of the tissue are so 
characteristic as to leave little doubt of the carcinomatous nature of 
the growth. It is scarcely necessary to resort to the microscope 
to confirm the diagnosis. 

III. The diagnosis of carcinoma of the body of the uterus presents 
the greatest possible difficulties. There are no symptoms that may 
be regarded as pathognomonic ; the lesion is beyond the reach of 



288 SPECIAL DIAGNOSIS. 

the examining finger, and cannot be brought under inspection. The 
general nutrition of the individual bears little relation to the stage 
of the growth. She may retain her weight into the last stage. 

Hemorrhage, a foul- smelling discharge, and pain occur in the 
order named, but it is possible for one or all of these symptoms to 
be absent, and more often there is nothing in the symptoms to 
suggest anything more serious than endometritis. 

If every menstrual irregularity occurring late in life, and every 
intermenstrual or 'postmenopausal hemorrhage were regarded with 
suspicion of carcinoma, and a thorough search made into the cause, 
few carcinomata of the uterus would long go unrecognized. 

It is usual for the menstrual periods to have been regular, for the 
menopause to have passed in the ordinary way, and for some 
months or years to have intervened before the appearance of hemor- 
rhage. The author lately saw a case in which the menopause had 
been passed forty-eight years when hemorrhage returned. Even 
with this long interval the patient and friends thought the loss of 
blood was due to a return of the menses. Their suspicions were 
confirmed to their entire satisfaction when the flow of blood ceased 
in a few days and returned in four weeks. This disposition on the 
part of the patient to believe that postmenopausal hemorrhages are 
the return of the menses is too frequently responsible for the high 
rate of mortality in carcinoma of the uterus. 

There is little difference in the subjective signs of carcinoma of the 
body of the uterus and those of the cervix or vaginal portion. The 
constitutional effects appear much slower. It is impossible to say 
when the growth begins. We commonly date the appearance of 
the carcinoma from the time of the onset of the watery discharge or 
hemorrhage, but it is to be borne in mind that these symptoms may 
be due to endometritis which has not as yet developed into a malig- 
nant growth ; and, on the other hand, these symptoms may follow 
weeks and months after the beginning of malignant degeneration. 
The slow growth of carcinoma of the body of the uterus is illustrated 
by a case of Cullen's, in which the hysterectomy was performed two 
years after the onset of symptoms, and in which the disease was 
seen to have made little progress. 

In a case operated upon by Dr. J. Clarence Webster the symptoms 
began three years previous to the operation. The growth was still 
apparently confined to the body of the uterus. 

We now see that the subjective signs cannot be relied upon in 



THE DIAGNOSIS OF CARCINOMA OF THE UTERUS. 289 

making a diagnosis, and that we must depend largely upon physical 
signs. 

Bimanual palpation of the uterine body shows a slight uniform 
enlargement, together with some degree of softening. In the early 
stage the size and consistency of the uterus is not changed. In 
the advanced stage, when the growth has extended to the serosa, 
small nodules may be palpated on the outer surface of the uterus, 
giving the impression of small subperitoneal fibroids. 

Exploration of the uterine cavity is essential to a positive diag- 
nosis. This is accomplished by the examining finger, the sound, 
or the curette. 

After dilating the cervix sufficiently to admit the index finger, 
the entire surface of the endometrium can be explored. Soft, 
friable, and irregular elevations upon the surface are located, and 
may be scraped off by the finger for a microscopic examination. 
It is possible in the early stage for a growth that is not distinctly 
raised above the surface to escape the examining finger. 

The uterine sound will detect the irregularities upon the sur- 
face of the endometrium with less certainty, and will afford much 
less intelligent information regarding the consistency and extent of 
the growth. In carcinoma the sound will sink into the soft growth 
and cause considerable bleeding. 

An exploratory curettage followed by a microscopic examination 
of the scrapings will supply an absolute means of making a diag- 
nosis, and should be made in every case, no matter what the other 
findings may be. 

Microscopic Diagnosis of Carcinoma of the Uterus. We have 
learned that an early diagnosis of carcinoma of the uterus is seldom 
made from clinical manifestations or from the naked eye appear- 
ances of the growth ; that the only positive means of making an 
early diagnosis is by a microscopic examination of excised pieces 
and of scrapings removed by the curette. 

I. Carcinoma of the Vaginal Portion of the Cervix. In advanced 
cases where there is ulceration of the cervix and where the vagina 
and parametrium are infiltrated, a microscopic examination is 
seldom necessary. In the early stage no characteristic features 
may be observed by the naked eye, and it is in such cases that the 
microscope is indispensable. 

The technic of excising a piece of the cervix for a microscopic 
examination is to sterilize the vagina as for a vaginal operation ; 

19 



290 SPECIAL DIAGNOSIS. 

grasp the cervix with a tenaculum and with knife or scissors 
remove a wedge including part of the suspected portion and part of 
the apparently healthy tissue. Following the incision catgut sutures 
are used to close the wound, and the vagina is packed with gauze. 
An anaesthetic is desirable, though not absolutely necessary. 

Fig. 147. 



The microscopic appearance of an infiltrating squamous-cell carci- 
noma of the cervix is that of many layers of flat epithelium varying 
greatly in size and in form from the normal epithelium of the 
vaginal portion. The cells may be no larger than a leucocyte, or 
considerably larger than normal. The nuclei are relatively large, 
often segmented. They take a deep stain and show many karyo- 



FlG. 148. 



w 



kinetic figures. A variable amount of protoplasm surrounds the 
nuclei. The cells, grouped in irregularly projecting columns, invade 
the underlying tissues and may finally wholly replace the cervix. 
About the margins of these projecting columns is a round-cell infil- 
tration of the connective tissue stroma. Cross-sections of these 
epithelial columns appear as " cancer nests " (Fig. 154), and in them 
" cancer pearls " (Fig. 153) are found. 



THE DIAGNOSIS OF CARCINOMA OF THE UTERUS. 291 

The microscopic diagnosis of a cauliflower carcinoma of the vaginal 
portion of the cervix is to be made from an excised piece of the 
suspected portion. The sections must be made perpendicular to 

Fig. 149. 



.'"'"" ; '-'-_■ I i ■ - si-'' S" - 

^ &]£ <^ : c JPW 






Papillary carcinoma of the cervix. 
Fig. 150. 



' ^ 



ae s 



: %r^ 



Squamous-cell carcinoma of the cervix. 
Fig. 151. 



Proliferation of the superficial columnar epithelium. The new-formed epithelium is seen to 
invade the connective tissue in the act of forming a malignant gland. 



292 



SPECIAL DIAGNOSIS. 



the cervix, in order to observe the epithelial invasion of the latter. 
The finger-like projections which aggregate to make a cauliflower 
growth are composed of a framework of connective tissue which 
contains a central bloodvessel, many round cells, and a variable 
number of invading epithelial cells (Fig. 1 55). The surface is covered 
with many layers of squamous epithelium not unlike those described 
above in the infiltrating form of carcinoma. The epithelium 
invades the underlying connective tissue of the cervix, and it is 
this feature that gives the malignant character to the growth. 
Cancer nests may show various stages of degeneration. Giant cells 
are relatively abundant. Hyaline degeneration of the cancer cells 
is common and the nuclei may be fragmented. 



Fig. 152. 





S 2» <?•***.£ ^JS'Jz? ^~*Z^ '"'%'^'J?' «v *•**?*? *®>> ^'"ClT' "***£L «." 

* *-- -*■ " - ^ ^ - - s =,« r " ' ~ x ?-■ -> vx - j~*- %z~ i 



*" ^""SeT"* ' 






Proliferation of the superficial columnar epithelium. The new-formed epithelium extends 
outward, forming papillary projections into which connective tissue fibres project to form a 
framework. There is no invasion of the connective tissue. The figure represents the begin- 
ning of a malignant papillary growth. 

Erosion carcinoma is a term implying malignant degeneration of 
an erosion of the cervix. The malignant changes commonly begin 
on the surface of the erosion, less frequently from the glands and 
follicles. In this way it is possible to have cylindrical-cell carcinoma 
in the vaginal portion of the cervix. 

II. Carcinoma of the Cervix. Two general histological forms of 
carcinoma of the cervix are recognized — alveolar and glandular. 
These forms take their origin from the surface epithelium or from 
pre-existing glands. In either form the wall of the cervix may 
be deeply infiltrated and the cervical canal filled. Ruge and Veit 
describe a budding process in the development of malignant gland 
formations. Groups of epithelial cells bud from either side of the 



THE DIAGNOSIS OF CARCINOMA OF THE UTERUS. 293 

lumen of a gland and unite to form a bridge across the gland. Event- 
ually the lumen of the gland may be filled with epithelial cells. 

In no essential way does carcinoma of the cervix differ from 
carcinoma of the body of the uterus. 

Fig. 133. 




Cancer pearl composed of concentric layers of hornified epithelium. 

III. Carcinoma of the Body of the Uterus. In carcinoma of the 
body of the uterus we see a great variety of histological forms. In 
general there are found the adenocarcinoma and the alveolar, very 
rarely the squamous-cell carcinoma. 

Fn. 154. 




Cancer nest with a necrotic centre. 



Adenocarcinoma may assume a type sometimes spoken of I as 
malignant adenoma — i. e., a glandular growth in which the glands 
are greatly increased in number and invade the musculature. 
There is but a single layer of epithelium, and the glands are very 
irregular in outline and often increased in size. It is difficult to 



294 SPECIAL DIAGNOSIS. 

differentiate an early malignant adenoma from an advanced type of 
hyperplastic glandular endometritis, or what is sometimes called a 
benign adenoma. Gebhard describes two varieties of malignant 
adenoma — the everted form, in which the glandular irregularities 
project outward from the lumen ; and the inverted form, in which 
the irregularities project into the lumen of the gland. The two 
forms are often combined. 

Fig. 155. 



r 



A finger-like projection of a squamous-cen carcinoma of the cervix. 

When in addition to irregularity in outline and great increase in 
the number of the glands the epithelium proliferates to form two 
or more layers and the basement membrane is broken through, we 
have formed the adenocarcinoma. 

Alveolar carcinoma may form by the complete filling up of the 



THE DIAGNOSIS OF CARCINOMA OF THE UTERUS. 295 

gland lumen in the advanced stage of adenocarcinoma, or the sur- 
face epithelium may invade the underlying tissue, giving rise to 
the formation of " cancer nests. " 



SQUAMOUS-CELL CARCINOMA OF THE BODY OF THE UTERUS. 

There are but few authentic cases of squamous-cell carcinoma of 
the body of the uterus reported. To deny the possible existence of 
such growths, as does Cullen in his admirable work on Cancer of 
the Uterus, is unwarranted from a study of the recorded cases. 
That multiple layers of squamous epithelium of a perfectly benign 
character are found has been well established by Veit, Gebhard, 
Ries, and others. It is only reasonable to infer that such benign 
metamorphosis may in turn become transformed into squamous-cell 
carcinomata. 

Zeller, in 1885, observed in the scrapings of all forms of endo- 
metritis isolated areas of stratified squamous epithelium showing 
none of the characters of a malignant growth. Gebhard and 
Menge made similar observations in gonorrheal endometritis. 
TTerth examined the mucosa ten days after curettage, finding islets 
of squamous epithelium in the mouths of glands. Gottschalk and 
Winkler record similar observations in the endometrium of preg- 
nancy in the fifth and third months, respectively. Optiz and 
Gebhard found small papillary elevations in the decidua, composed 
of three or four layers of squamous cells. Meier and Friedlander 
made observations on the uteri of foetuses and infants, in which 
they demonstrated isolated patches of squamous epithelium, four to 
six layers in thickness, the lowermost layer being cylindrical, the 
uppermost layer hornified, and the intermediate layer cubical in 
form. Heugge reports two cases, forty-four and forty-nine years 
of age, in which curettage was performed for the control of hemor- 
rhage. In both were found transformation and proliferation of 
the epithelium into stratified squamous epithelium, occupying the 
glands and the surface of the mucosa. 

In none of the above recorded cases was there evidence of malig- 
nancy. The benign metamorphosis occurred from the ninth month 
of foetal life to the forty-ninth year. Bebkiser, Hofmeier, and 
Gebhard each described a case in which the benign stratified epithe- 
lium became transformed into a malignant squamous epithelial 
growth. Kaufman curetted the uterus of a woman, aged sixty- 



296 SPECIAL DIAGNOSIS. 

four years, who had suffered from uterine hemorrhage six years. 
In the scrapings were typical fields of adenocarcinoma, together 
with nests of squamous-cell carcinoma containing cancer pearls. 

It is probable, as Winter says, that these growths never arise 
directly from cylindrical epithelium. It is more likely that through 
mechanical, chemical, and myotic influences the cylindrical cells 
proliferate, become flattened, and subsequently undergo malignant 
transformation. 

Plate XXXVI. is drawn from a specimen removed by Dr. J. 
Clarence Webster in the Presbyterian Hospital of Chicago. In the 
specimen is an interstitial fibroid of the uterine body lying directly 
posterior to a cauliflower growth of the endometrium. This endo- 
metrial growth is about two inches in diameter, is soft and friable, 
and shows no visible degenerative changes. The remainder of the 
endometrium is apparently normal. Microscopic sections show an 
adenocarcinoma ; typical in form and intimately associated with 
malignant glands are areas of apparently squamous-cell carcinoma. 
In the field will be seen glands partially filled with flat epithelium, 
and cells showing transition stages from the cylindrical to the flat 
cells. Xo cancer pearls are found. After a thorough search through- 
out the endometrium not involved in the cauliflower growth, I 
could find no evident metamorphosis of the surface epithelium. 
It is probable that the existence of the flat epithelium may be 
accounted for by the presence of the encroaching fibroid — a result 
of pressure. 

I. Differential Diagnosis of Carcinoma of the Uterus. Car- 
cinoma of the vaginal portion of the cervix is to be differentiated from 
eversion of the mucous membrane, erosions of the cervix, decubitus, 
tuberculous and syphilitic ulcers, follicular degeneration of the 
cervix, metritis coli, and sarcoma. 

Eversion of the mucous membrane of the cervix follows laceration 
of the cervix. Viewing the cervix through a speculum, the eversion 
is often exaggerated by the traction made by the speculum upon 
the cervix. Grasping the two everted lips of the cervix with 
tenacula and bringing them together the everted mucous membrane 
is rolled in, leaving a normal appearing cervix. The suspected 
portion is not friable, and does not bleed freely when handled. 
Finally, if a section of the everted mucosa is examined under the 
microscope, it is seen to be either normal or hypertrophied. There 
is no evidence of an epithelial invasion of the underlying tissue. 



PLATE XXXVI 



'V,'- .„. ., -v 






.- ~ «f "' 


•*,' - 


«^V> . ,; . 




'-■ . -' "-"' 


«- \,;'\ ?■* r-j\y' 


£ '•'*- ^ : 


' .*•' * - '- . ft 




" ■ : =. •' ~ f - . 




,?';-= 


1 f ' " .v .' •■ •..- !i''„.r 






' . -','i - • / ' ' 


*-*^^ ■- 












, ? -; ( ^ ^M'/- ■ 1 








-/ £ »,^ ■ c i.*-'* '■' ■ 


~<-'s v- ^ <*■■ ^ 


ft. 


$. Mm. 'II m 




Fill 

■\;- ■..'■£ f<i**2 

'. .-■ ''--■*-> -■ <y«\<* °« 
V, ,\ x~~- - * J 9 * 

* | eA'-pr- yy a"- , N ^ i 



3$8 



g^;:; iylmy ; 4 t?^ 



O^V^CaSTk ;" 



Combination of squamous-eell carcinoma and adeno- 
carcinoma of the corpus uteri. 



THE DIAGNOSIS OF CARCINOMA OF THE UTERUS. 297 

Erosions of the cervix (mucous patch) may be confused with car- 
cinoma when having a papillary surface or when deeply indurated. 
Erosions seldom bleed so freely as does carcinoma, and the tissue is 
less friable. Where doubt exists a microscopic examination of an 
excised piece of the suspected portion will confirm the diagnosis. 
No epithelial invasion will be found beneath the basement membrane. 

Decubitus ulcers of the cervix due to pressure from ill-fitting 
pessaries and friction of the cervix and thighs in prolapsus uteri 
are recognized by their punched-out appearance, the absence of 
hard, elevated margins, the granular bed in the absence of indura- 
tion, and, finally, by a microscopic examination of excised pieces of 
the ulcers in which there is found no epithelial invasion of the 
underlying structures. On removal of the pessary and replacing 
the prolapsed uterus there is a tendency to healing, which is never 
present in carcinomatous ulcers. 

Tuberculous ulcers of the cervix are rare as compared with car- 
cinoma. A tuberculous family history, the presence of tuberculosis 
elsewhere in the body, and particularly in the upper genital tract, 
will suggest the possible nature of the lesion. The tuberculous 
ulcer has a ragged, undermined margin in contrast to the hard, 
elevated margin of a carcinomatous ulcer. The bed of the ulcer is 
not indurated as in carcinoma, and may be studded with tubercles 
and covered with a yellowish secretion. Miliary tubercles may sur- 
round the margins of the ulcer. There is not the tendency to bleed 
when handled, nor is the tissue so friable as in carcinoma. Finally, 
a microscopic examination of excised pieces will reveal the tubercles, 
giant cells, and possibly the tubercle bacillus, and there will be an 
absence of deep invasion by the epithelium. There is a tendency 
to heal by cicatrization not seen in cancerous ulcers. 

Bayea speaks of ulcerative, miliary, papillary, and hyperplastic 
tuberculous endocervicitis. Papillary tuberculous endocervicitis, 
according to Bayea, is distinguished from a cauliflower carcinoma 
by the following : 

1. Not bleeding so freely or so early as carcinoma. 

2. More elastic and velvety and less friable than is carcinoma. 

3. Commonly occuring during the period of sexual maturity, 
while carcinoma occurs later. 

4. Great variations in history and in duration. 

5. Microscopic examination showing lesions typical of tubercu- 
losis and the absence of epithelial invasion. 



298 SPECIAL DIAGNOSIS. 

A syphilitic ulcer is single, shallow, and deeply indurated ; the 
bed of the ulcer is covered with a grayish-yellow deposit, and the 
margins are not elevated but are described as serpiginous. There 
is a tendency to heal by cicatrization. Multiple ulcerated papules 
may be present. Under the microscope there is noted an absence 
of epithelial invasion of the cervix. 

Follicular degeneration of the cervix, or, what is commonly known 
as a follicular erosion, is described on page 251. The cervix may 
be considerably enlarged, irregular, and nodular. Cutting into the 
irregular elevations, inspissated mucus escapes. The suspected 
tissue is tough, not friable as in carcinoma, and does not bleed 
when handled. The microscope shows distended glands, with an 
intact, overlying mucosa not invading the underlying connective 
tissue. 

An interstitial fibroid of the cervix is commonly associated with 
similar growths in the body of the uterus. The tumor is firm, 
sharply circumscribed, and shows no tendency to friability and 
bleeding. On cross-section and under the microscope a fibrous or 
fibromuscular structure is seen. 

Metritis coli is a chronic inflammation of the cervix causing such 
thickening and hardening of the tissue as to suggest malignant 
infiltration. The enlargement is uniform as contrasted with the 
irregular growth of the carcinomatous cervix ; there is an absence 
of the cartilaginous firmness of the cervix of the first stage of car- 
cinoma, and there is no bleeding on handling. In doubtful cases a 
section of the suspected tissue should be submitted to the microscope. 

Sarcoma of the cervix cannot be diagnosed from carcinoma with- 
out the aid of the microscope. The clinical history and the naked 
eye appearance of the growth will not suffice for a diagnosis. 

Abel lately claims to have hit upon a valuable diagnostic point 
in squamous-cell carcinoma of the cervix. He finds by the Weigert 
resorcin-fuchsin stain the presence of elastic fibres surrounding the 
nests of epithelium and running between individual epithelial 
cells. In benign epithelial growths, such as condyloma of the cer- 
vix and papillary erosions, elastic fibres are found at the margins 
of epithelial groups and do not run between individual cells. 

II. The differential diagnosis of carcinoma of the cervix is 
made from mucous polyps, submucous fibroids, and cystic degenera- 
tion of the glands of the cervix. In all of these the absence of 
friability, the slight bleeding when handled, finally, and conclu- 



THE DIAGNOSIS OF CARCINOMA OF THE UTERUS. 299 

sively, a microscopic examination of the suspected tissue, determine 
its identity. 

III. The differential diagnosis of carcinoma of the body of 
the uterus is from endometritis, submucous and interstitial fibroids, 
retained placental tissue, syncytioma malign um, hydatiform mole, 
arterio-sclerosis, sarcoma, and endometritis. 

Endometritis may closely resemble carcinoma of the body of the 
uterus in its clinical manifestations, and in its macroscopic and 
microscopic appearances. 

The symptoms of endometritis may be identical with those of 
carcinoma. In both of these lesions all symptoms may be absent 
or so insignificant as not to concern the patient. 

A naked eye examination of the endometrium after removal of 
the uterus or of scrapings removed from the uterus, while sufficiently 
characteristic in many cases, may be altogether misleading. It not 
infrequently happens that the only way to make a positive diagnosis 
is by the aid of the microscope. Indeed, it is only by an exploratory 
curettage and a microscopic examination of the scrapings that an early 
diagnosis of carcinoma of the uterus can be made. 

Carcinoma of the body of the uterus is so insidious in its development 
and so slow in its progress that it becomes imperative to regard with 
suspicion all hemorrhages, however slight, when occurring late in life, 
and to advise an exploratory curettage when the cause of the hemor- 
rhage is not accounted for. 

In making a microscopic examination of suspected scrapings from 
the uterus we are to determine whether the glands are more irreg- 
ular in outline than the glands of hyperplastic and hypertrophic 
endometritis ; whether they are so increased in number as to do 
away with the interglandular connective tissue to an extent not 
observed in endometritis, and, finally, whether the epithelium is 
proliferated and broken through the basement membrane and is 
found within the interglandular connective tissue. These three 
findings — that is, great irregularity of the glands, great increase in 
number of the glands, and proliferation of the epithelium beyond 
the basement membrane — serve to distinguish adenocarcinoma and 
malignant adenoma from glandular endometritis. One, two, or all 
three of these features may be found, and are to be regarded as 
characteristic. The last, however, is by far the most reliable. 
Occasionally there will be found a specimen, the character of which 
cannot be determined with certaintv. Such cases should either 



300 SPECIAL DIAGNOSIS. 

be treated as if malignant or should be kept under close obser- 
vation. 

Submucous and interstitial fibroids may present all the clinical 
evidences of malignancy. This is especially true in gangrene of 
the fibroid. Hemorrhage, leucorrhoea, pain, and emaciation may 
all be in evidence, and suggest the presence in the uterus of a 
malignant growth. An exploratory curettage and a microscopic 
examination of the removed particles will establish a diagnosis. 

A fibroid bulging into the uterine cavity may be identified by a 
sound, curette, or the examining finger. It is to be borne in mind 
that fibroids and carcinoma may coexist in the body of the uterus, 
and we are not to be content with the finding of any single cause 
for the symptoms, but are to exclude all possible causes. 

Retained Placental Tissue. Portions of the placenta may be 
retained in the uterus an indefinite length of time — weeks, months, 
and years after the termination of labor and abortion. Hemor- 
rhage, leucorrhoea, and pain may result, giving a clinical picture 
that may be mistaken for carcinoma of the body of the uterus. 
The lesion is most likely to be found during the period of sexual 
maturity, while the symptoms of carcinoma of the uterine body 
seldom appear before the climacteric period, and more often some 
time after the menopause. 

A positive diagnosis can only be made by an exploratory curet- 
tage and a microscopic examination of the scrapings. In recent 
cases the placental tissue may be recognized by the naked eye, but 
in cases of long standing mere shadows of placental tissue may be 
recognized by the microscope The presence of decidual cells and 
chorionic villi in the scrapings determines the diagnosis. 

The glands of pregnancy are so varied and irregular in form as to 
suggest the possibility of malignancy where pregnancy has not been 
suspected. The interglandular connective tissue may be almost 
entirely lost by pressure of the enlarged glands. The glands 
seldom run at right angles to the surface and may run almost 
parallel. Their outlets are constricted by the surrounding decidual 
cells, while their deeper portions are widely distended. As a rule, 
a single layer of epithelium lines them, but more than one layer 
is occasionally found. The epithelium is flattened or cuboidal. A 
number of layers of flat epithelium have been observed in the 
glands. There is, however, no invasion of the interglandular con- 
nective tissue by the epithelium, and herein lies the differentiation 



THE DIAGNOSIS OF CARCINOMA OF THE UTERUS. 301 

from malignant glands. The finding of decidual cells surrounding 
the glands will suggest their character. 

Mucous polyps of the uterus are frequently the cause of hemor- 
rhage. While more common during the age of sexual maturity, 
they may be found at any age, even years after the menopause. 
The microscopic picture does not differ essentially from that of 
endometritis. The absence of epithelial proliferation and invasion 
of the underlying connective tissue will exclude carcinoma. 

The decidua of ectopic pregnancy may be confused with carcinoma 
where pregnancy is not suspected. The scrapings from the uterus 
of an ectopic pregnancy may appear to the naked eye not unlike 
those from a carcinoma. Viewed under the microscope no doubt 
should arise. In association with the decidual cells are the glands 
of pregnancy, giving a picture not to be confused with carcinoma. 

Tuberculous endometritis may closely simulate carcinoma in its 
clinical and anatomical features. 

Tuberculosis of the endometrium usually occurs early in life as 
compared with carcinoma of the uterus. There may be a family his- 
tory of tuberculosis, or tuberculous foci may be found elsewhere in 
the body. If found in the tubes, it is altogether probable that the 
endometrium will be involved. In exceptional cases the diagnosis 
can be made from cover-slip preparations of the leucorrhoeal dis- 
charge. To the naked eye the endometrium may present the char- 
acteristic ulcers and tubercles, but in general it may be said that 
in the absence of tuberculosis in other portions of the genital tract, 
the lesion can only be diagnosed from endometritis or carcinoma 
by microscopic examinations of sections taken from the uterus after 
removal, or from scrapings. The finding of tubercles, giant cells, 
or tubercle bacilli and the absence of epithelial invasion of the con- 
nective tissue will complete the diagnosis. The picture is distinctly 
that of an inflammatory reaction. 

DIAGNOSIS OF EXTENSION OF CARCINOMA OF THE UTERUS. 

It is of prime importance to determine whether or not the carci- 
noma is confined to the uterus. This should always be done before 
the diagnosis can be considered complete and before determining 
upon radical procedures in treatment. 

It is now generally conceded that the entire uterus must be 
removed for carcinoma involving any part of the organ ; hence it is 



302 SPECIAL DIAGNOSIS. 

no longer a question as to how much of the uterus is involved in 
the growth, but rather as to whether it is confined to the uterus or 
has spread to the surrounding structures. We look to the para- 
metrium, vagina, bladder, rectum, lymph glands, and internal 
organs for secondary growths. 

The 'parametrium, particularly that portion of the cellular tissue 
found betwen the layers of the broad ligaments, is involved com- 
paratively early. In carcinoma of the cervix and vaginal portion 
the base of the broad ligament is invaded. The infiltrated tissue 
is felt as a " board-like " mass, irregular and nodular in outline, 
firmly fixed, and not tender to pressure. The cervix is crowded to 
the opposite direction. 

The examination is best made under anaesthesia. Two fingers 
are placed in the rectum, the thumb in the vagina. Counter- 
pressure is made over the abdomen by the other hand. The cervix 
and area of infiltration will be found as one mass. The cervix will 
be immovable. This immobility of the cervix does not necessarily 
signify a carcinomatous invasion ; it may well be inflammatory. 

Inflammatory swellings of the tubes and ovaries fixed by the side 
or behind the uterus may be mistaken for carcinomatous infiltration. 
Such swellings are more tender to pressure, are less cartilaginous 
in consistency, have not the same intimate connection with the 
cervix, and are commonly located on a higher plane. 

Still greater difficulty is experienced in differentiating carcino- 
matous infiltration of the parametrium from pelvic cellulitis. In 
the latter there is greater tenderness, the outline is flatter and less 
nodular, and there may be no direct and immediate connection 
between the carcinomatous lesion in the uterus and the infiltrated 
parametrium. The cervix is crowded away from the growth, while 
in parametritis the cervix is drawn to the infected side. 

It is difficult to demonstrate carcinomatous infiltration of the con- 
nective tissue occupying the vesico-uterine space. Usually it is not 
possible until an incision is made into the region. The uterosacral 
ligaments may be infiltrated. The characteristics of the lesion and 
the differentiation from an inflammatory involvement of the same 
structures are as found in invasion of the broad ligaments. 

The vagina is invaded by direct extension, seldom by metastasis. 

Since carcinoma of the vaginal portion more often begins in the 
anterior lip, the anterior wall of the vagina is frequently first 
attacked. The infiltrated vaginal wall is readily recognized by the 



THE DIAGNOSIS OF C ARC IN 031 A OF THE UTERUS. 303 

finger and by examination through the speculum. The infiltrated 
area in the vagina is directly continuous with the growth in the 
cervix. The margins of the infiltrated area are elevated, hard, and 
irregular. Ulceration follows in the late stage, and such ulcers 
show the irregular, elevated margins and the uneven base which 
bleeds freely on being touched. Metastatic groAvths may be found 
at any point in the vaginal walls, more often in the posterior wall. 
Such growths are hard and nodular, and may attain the size of a 
walnut. 

When the paravaginal tissue is infiltrated it is possible to move 
the vaginal mucous membrane independently of the underlying 
growth. 

Spiegelberg's sign is of some value in recognizing a carcinomatous 
infiltration beneath an intact mucous membrane. Passing the 
finger over the surface the mucous membrane feels like wet 
rubber, having lost its normal pliability. 

Invasion of the bladder is secondary to that of the anterior wall 
of the vagina. It is clinically recognized by frequent and painful 
urination, blood in the urine, and, finally, by the dribbling of urine 
into the vagina through a vesicovaginal fistula. An early diagnosis 
is made by cystoscopic examination. The area of infiltration and 
the ulcers are distinctly detected, and when associated with advanced 
carcinoma of the cervix there can be no hesitancy in making the 
diagnosis of extension of the carcinoma to the bladder. 

The rectum is invaded after the growth has spread to the pos- 
terior vaginal wall. The symptoms indicating invasion of the 
rectum are a mucous discharge which is often stained with blood, 
rectal tenesmus, constipation alternating with diarrhoea, and a dis- 
charge of feces through the vagina after the development of a recto- 
vaginal fistula. A digital exploration of the rectum and vagina 
reveals a hard, infiltrated area in the rectovaginal septum, which 
bleeds and may crumble to the touch ; the mucous membrane of 
the rectum has lost its pliability, and cannot be moved indepen- 
dently of the underlying structures ; and, finally, a section removed 
for microscopic examination determines the diagnosis. 

Metastatic growths are seldom early in making their appearance. 
Experience teaches us that it is never possible to say with absolute 
certainty that metastasis has not occurred even in the apparently 
early growths. The ovary is sometimes the seat of metastasis. Of 
the abdominal and thoracic viscera those most often involved are 



304 SPECIAL DIAGNOSIS. 

the lungs and liver. In carcinoma of the uterine body the lumbar 
glands are first involved. If the horn of the uterus is invaded the 
deep inguinal glands may be attacked by way of the round liga- 
ment. In carcinoma of the cervix, the vaginal portion of the cervix 
and the upper segment of the vagina, the iliac glands lying in front 
of the sacro-iliac synchondrosis at the bifurcation of the common 
iliac vessels are first invaded. In carcinoma of the vulva and lower 
segment of the vagina the inguinal glands are first attacked. It is 
of the greatest importance to recognize involvement of the lymphatic 
glands in settling the question of operative interference. 

The diagnosis of recurrence after removal of the uterus is of great 
importance. A recurrence implies failure of having thoroughly 
removed the primary focus. 

Winter speaks of local recurrence when the secondary develop- 
ment is in or near the previous field of operation ; of lymph gland 
recurrence when the lymphatic glands of the body are involved sub- 
sequently to the operation, and of metastatic recurrence when the 
carcinoma spreads by way of the blood stream to distant parts of 
the body. 

The great liability of recurrence in carcinoma of the uterus admon- 
ishes us to always give a guarded prognosis, no matter how early and 
thoroughly the operation may have been performed. 

The general symptoms indicating a recurrence are loss of flesh 
and strength, cachexia, foul-smelling leucorrhoea, irregular hemor- 
rhages, and pain in the pelvis radiating to the thighs, groin, rectum, 
back, and abdomen. A positive diagnosis can only be made from 
a physical examination. Local recurrence in the tissues about the 
uterus is recognized by the cartilaginous consistency of the areas of 
infiltration in the vagina and broad ligaments. 

Granulation tissue in the scars at the end of the stumps may be 
regarded with suspicion. They are seldom so hard and friable as 
carcinoma, and a microscopic examination of an excised piece or 
scraping will determine the diagnosis. It is not always possible to 
say of enlarged glands that they are so from carcinomatous involve- 
ment. It is possible that their enlargement is the result of infection. 

ENDOTHELIOMA. 

By endothelioma is meant a malignant new formation arising 
from the endothelium of blood and lymphatic vessels and from 



THE DIAGNOSIS OF CARCINOMA OF THE UTERUS. 305 

serous surfaces. Endothelioma appears at any time in life. The 
earliest reported case is that of Braetz, at eighteen years of age. 

Such growths differ from carcinoma and sarcoma, not only in 
their histogenesis, but also in their histological structure. 

In their gross appearance there is nothing distinctive. Under 
the microscope the lumina of blood and lymph spaces are seen to 
be distended with rapidly proliferating endothelium. The neigh- 
boring connective tissue and bloodvessels may be invaded. The 
individual cells assume a variety of shapes, and are not always 
recognized as endothelial in origin. The flat cells become irregular 
in outline and swollen, and the nuclei take a deep stain. It may be 
possible to identify these cells by tracing them to their origin in 
the walls of vessels, where they are not so changed in structure. 

It is puzzling to differentiate between a carcinoma invading the 
lymph spaces and an endothelioma arising from the lymph spaces. 
In lymphatic carcinoma the appearance is that of veins of marble 
in the stroma. 



20 



CHAPTER XXVII. 

THE DIAGNOSIS OF SARCOMA OF THE UTERUS. 

From the older literature we are led to believe that sarcoma of 
the uterus is an extremely rare condition. Roger Williams and 
Gurlt reported ten sarcomata in 6764 tumors of the uterus. Doubt- 
less many sarcomata were regarded as carcinoma through failure to 
make a microscopic examination. Some were regarded as fibroids 
and were spoken of as recurrent. 

Whitridge Williams, in his Contribution to the Histology and 
Histogenesis of Sarcoma of the Uterus, reported 114 uterine sar- 
comata in the literature. The proportion of sarcoma to carcinoma 
in the uterus is said to be 1 : 40. 

Etiology. Nothing is known of the essential cause of sarcoma. 
What has been said of Cohnheim's theory receives no confirmation 
in sarcoma. Inflammatory lesions and trauma seem to bear no 
causal relation, nor does childbearing. Fully two-thirds of the cases 
are found in women who either have not borne children or have 
given birth to less than the average number. We find no age 
exempt from infancy to the postclimacteric period. A case has been 
lately reported in which a hysterectomy was performed at three 
years of age. Pick reports a case at two years of age. The oldest 
case recorded was seventy years. Gusserow reported seventy-three 
cases, of which four were under twenty-nine years of age ; fifteen 
were from thirty to forty years ; twenty-eight from forty to fifty ; 
eighteen from fifty to sixty, and three were over sixty years of 
age. 

Anatomical Diagnosis. As in carcinoma of the uterus, sarcoma 
is found in the vaginal portion of the cervix, in the cervical canal, 
and in the body of the uterus. 

1. Sarcoma of the Vaginal Portion of the Cervix. This is an 
uncommon location for sarcoma. To the naked eye there is no 
way of distinguishing this growth from carcinoma. There are the 
cauliflower and the infiltrating forms, resembling those found in 
carcinoma of the vaginal portion. 



THE DIAGNOSIS OF SARCOMA OF THE UTERUS. 307 

II. Sarcoma of the cervix is distinctive when assuming, as it 
usually does, a grape-like form (sarcoma botryoides). The mass 
protrudes from the external os and hangs into the vagina as trans- 
parent vesicles, appearing not unlike a vesicular mole. This form 
is more often found in childhood, but may appear in old age. 
Pfannenstiel found 50 per cent, in nullipara?. A similar growth is 
sometimes seen in the body of the uterus due to oedema or myxo- 
matous degeneration of the growth. Carcinoma of the cervix never 
assumes this vesicular form. 

Sarcoma of the cervix may form a diffuse infiltration of the cer- 
vical tissue or protrude from the surface as a tubercular, polypoid, 
or cauliflower growth. 

III. Sarcoma of the body of the uterus arises from any of the 
mesoblastic structures. Very commonly the growth is a malignant 
transformation of a pre-existing fibroid tumor. 

a. Sarcoma of the submucosa may take the form of a diffuse infil- 
tration or of a papillary or nodular growth projecting from the sur- 
face. The surface of these growths is never shaggy as in carcinoma. 

The color varies from pale gray to dark red. Their consistency 
is soft and often friable. 

The growth rarely begins as a diffuse involvement of the mucosa, 
but rather as a circumscribed lesion extending by continuity of 
surface and by metastasis. 

b. Sarcoma of the wall of the uterus generally arises from sub- 
mucous or interstitial fibroids. The fibrous structure of the tumor 
gives place to a homogeneous substance of soft consistency, varying 
in color from pale gray to dark red. The growth is rapid as com- 
pared to that of a fibroid. Recurrent fibroids were recognized in 
the days when the microscope was little used. They are now 
regarded as fibrosarcomata. 

Sarcoma spreads through the uterine wall to the peritoneum and 
to the abdominal and pelvic viscera. Metastasis to neighboring 
organs and to lymphatic glands is unusual. The point of earliest 
attack is the lung. The ovary is the seat of secondary invasion 
more often in sarcoma than in carcinoma. 

Microscopic Diagnosis. As elsewhere in the body, sarcoma is 
classified as round-cell, spindle-cell, or giant-cell. Very often there 
is a mixture of these cells. 

1. Round-cell sarcoma is composed of large or small rouDd cells 
having a large nucleus and a limited rim of protoplasm. The 



308 SPECIAL DIAGNOSIS. 

diameters of the cells vary from 4 to 15 micromillimetres. There 
is a variable amount of chromatin and an abundance of karyokinetic 
figures. Numerous newly-formed bloodvessels are seen. The sar- 
coma cells directly bound blood spaces. 

2. Spindle-cell sarcoma is composed of large or small elongated 
cells arranged in bundles and bands. On section they appear in 
various forms from round to spindle. Two or more nuclei are 
observed. The amount of chromatin varies greatly. 

3. Giant-cell sarcoma is a rare finding in the uterus. These cells 
may be 80 micromillimetres in diameter. They are polynuclear, 
and are rich in chromatin and mytotic figures. The nuclei vary 
in shape and in staining qualities ; vacuoles may be present. 

In all the above forms the fibrillar network may be so scanty 
that it escapes notice, or so abundant that the name fibrosarcoma is 
suggested. As a rule, the connective tissue framework is distributed 
uniformly between the cells, but nests of cells may be surrounded, 
by connective tissue giving the appearance of cancer nests (alveolar 
sarcoma). Newly-formed bloodvessels are prominent features of 
sarcoma, and may be sufficiently abundant to give to the tumor the 
name angiosarcoma. 

The intimate association of the blood channels with the sur- 
rounding sarcoma cells is characteristic. No sharp distinction can 
be made between the three microscopic forms. A mixture of two 
or three is the rule. 

Secondary changes in sarcoma tissue are of common occurrence, 
though not so frequent as in carcinoma, for the reason that sarcoma 
cells are more directly supplied with blood. Degenerative changes 
ordinarily begin in the centre of a sarcoma. The cells at the 
periphery do not usually suffer change. The degenerative forms 
commonly seen are the hemorrhagic, hyaline, and fatty. 

Mixed Tumors. The tendency of sarcoma cells to assume the 
mature type accounts for the frequency of the so-called myosarcoma 
of the uterus. Myxosarcoma is a myxomatous degeneration of the 
connective tissue stroma. Enchondrosarcoma, carcinosarcoma, and 
melanosarcoma are of extremely rare occurrence. 

Clinical Diagnosis. All that has been said of the clinical diag- 
nosis of carcinoma of the uterus applies to sarcoma. The clinical 
manifestations and physical findings do not materially differ from 
carcinoma. The differential diagnosis of carcinoma from sarcoma 
must depend upon the microscope. 



THE DIAGNOSIS OF SARCOMA OF THE UTERUS. 309 

The early recognition of sarcomatous degeneration of a fibromyoma 
is of the utmost importance. When a fibromyoma of the uterus 
undergoes malignant changes it takes on rapid growth, becomes 
softer in consistency, more pain is experienced in the region of the 
tumor, cachexia rapidly develops, ascites may make its appearance, 
and metastatic growths may arise in the lungs and elsewhere. If 
the tumor is interstitial or submucous, the hemorrhages will be 
greater. When a fibroid takes on a rapid growth, and particularly 
if near the time of the menopause, no time should be lost in remov- 
ing the growth. When after removal of a fibroid the growth 
returns, it is suggestive of sarcoma. 

The length of time a sarcoma may exist before destroying life is 
variable, and has been observed from two months to five years. 
The average time is estimated at two years. 



CHAPTER XXVIII. 

THE DIAGNOSIS OF DISEASES OF THE TUBES. 

Methods of Examination. Only under favorable conditions 
can a normal tube be outlined in a bimanual examination. If 
the abdominal walls are thick and tense an anesthetic will be 
required. 

The uterus is first located in an abdomino- vaginal examination. 
From the horn of the uterus the hand, passing outward toward the 
sides of the pelvis, should follow the tube a variable distance. The 
normal tube is made to roll under the examining finger like a cord. 
It appears to be about the size of a slate-pencil. At the fimbriated 
extremity the wall is so thin that it is impossible, under normal 
conditions, to palpate it. When the uterus is in retroposition, or 
when the tubes have fallen behind the uterus, or when the uterus 
and tubes are in their normal position and the vagina is small and 
sensitive, the recto-abdominal method of examination is preferable. 
In the unmarried a recto-abdominal examination should be done 
under anaesthesia. 

Where the tubes lie beyond easy reach of the examining finger, 
traction upon the cervix with vulsella forceps should be made by an 
assistant, while the recto-abdominal or vagino-abdominal method is 
carried out. 

May a sound be passed into the tube ? Undoubtedly the sound 
has been passed into diseased tubes, but it is questionable whether 
the normal tube has ever been sounded. It is very certain that the 
procedure should never be attempted for fear of penetrating the 
uterus. 

ANOMALIES IN THE STRUCTURE OF THE TUBES. 

1. Both tubes may be wanting, in which case the uterus is com- 
monly absent. 

2. A single tube may be wanting, in which case the corresponding 
side of the uterus is usually absent. 



THE DIAGNOSIS OF DISEASES OF THE TUBES. 



311 



3. One or both tubes may be rudimentary and associated with a 
rudimentary uterus. The tubes may remain infantile in type, very 
greatly convoluted, and have a small lumen. 

4. The lumen of the tube may be partially or completely oblit- 
erated or may be abnormally large. 

5. Rudimentary tubes or fimbria? may spring from the main 
tube. Leading into the main tube through the accessory tubes and 
fimbriae are rudimentary canals and ostia. 

Fig. 156. 




Ovary and Fallopian tube, from a woman forty-one years of age. Natural size. Atrophic pro- 
cesses and consequent decrease in size of the ovary and tube already begun. (Dudley.) 

Webster resected the fimbriated end of the tube, and some months 
later the abdominal cavity was again opened and the fimbriae were 
found to be regenerated. 

6. Diverticula of the endosalpinx are sometimes present, and are 
known to be a cause of tubal pregnancy. 



CHANGES IN THE POSITION OF THE TUBES. 

These changes may be congenital, but are more often acquired. 
In congenital malposition of the tubes there is usually a malposi- 
tion or maldevelopment of the uterus. In a uterus bicornis the 
tubes lie more to the sides of the pelvis than is normal. In a rudi- 
mentary uterus the tabes lie below the normal level. Congenital 
hernia of one or both tubes is a rare finding. 

Much more frequent are acquired displacements of the tubes. 
When the tube becomes enlarged and increased in weight, it tends 



312 SPECIAL DIAGNOSIS. 

to fall to a lower level at the side of or behind the uterus. Adhe- 
sions may pull the tube in any direction, and all swellings, whether 
inflammatory or new-growths, push the tubes into malpositions. 
Any displacement of the uterus will almost invariably displace the 
tubes. 

CIRCULATORY DISTURBANCES IN THE TUBE. 

Whatever interferes with the general or local circulation in the 
pelvis may cause congestion of the Fallopian tubes. Thus diseases 
of the heart, lungs, liver and kidney, abdominal tumors, ascites, 
chronic constipation, and tight lacing are among the causes of tubal 
congestion. 

Infectious diseases, the blood dyscrasias, burns, toxaemias, and 
menstrual congestion are additional general causes. A displaced 
tube, one that is twisted, constricted, or compressed, may cause 
congestion and possibly hemorrhages into the tube. 

Anatomical Diagnosis. The congested tube is slightly swollen, 
dark red in color, and offers unusual resistance to pressure. Hemor- 
rhages may be seen in the mucosa and in the lumen. Necrosis of 
the tube may result from interference with the blood supply. 
Martin describes a case of necrosis of the tube following a mitral 
insufficiency. 

When the ends of the tubes are closed and blood is extravasated 
into the lumen in sufficient quantity the tube will be distended 
into what is known as a hematosalpinx. For further description 
of hematosalpinx, see page 327. 

The microscope shows the vessels to be deeply congested with 
blood extravasated into the tube wall and lumen. W T hen there is 
necrosis the tissues stain poorly. 

Clinical Diagnosis. Perhaps a large proportion of cases goes 
unrecognized, partly because of the frequency with which the 
lesion exists in the absence of all clinical manifestations ; partly 
because of associated lesions. The menstrual periods are painful, 
and the functions of the bowel and bladder are performed with 
more or less discomfort. Tenderness on pressure over the affected 
tube is the one constant symptom. The diagnosis cannot be made 
with certainty without an exploratory incision. The existence of 
a possible cause, together with the finding of a tube that is some- 
what tender to pressure and slightly enlarged, will lead to a prob- 
able diagnosis. It is manifestly impossible to differentiate clinically 



PLATE XXXVII 







* >J/ 






f> . ' «> 



* 



/ 1 









Bacillus eoli communis, 



Gonoeoeeus. 







-c 




Streptococcus pyogenes. 



Bacillus tuberculosis. 





Pneumoeoeeus. 



Staphylococcus. 



Magnified lOOO times. 



THE DIAGNOSIS OF DISEASES OF THE TUBES. 313 

a congested tube from a catarrhal salpingitis ; the former is the 
forerunner and accompaniment of the latter. 

The diagnosis of hematosalpinx will be referred to on page 327. 

INFLAMMATIONS AND INFECTIOUS GRANULOMATA. 

General Considerations. Of all lesions of the tube the inflam- 
matory are most commonly observed. Of the various exciting 
causes of salpingitis we have the authority of !Noeggerath and 
Wertheim for placing the gonococcus at the head of the list of 
micro-organisms. In 302 cases of inflammatory lesions in the 
tubes, there were 83 in which living micro-organisms were found, 
and of this number 56 were gonococci, 11 were streptococci, 6 
staphylococci, 1 was the pneumococcus, while 122 were sterile. 
The fact that such a large percentage is sterile adds to the difficulty 
in determining the essential microbic cause. L. R. Guthrie col- 
lected statistics from operators in fifteen cities of Iowa, and con- 
cludes that 70 per cent, of inflammatory diseases of the tubes are 
of gonorrhceal origin. Neisser, in 143 cases, found the gonococcus 
in 80 after a latent period of from two months to eight years. He 
emphasizes the necessity of repeated examinations and faultless 
technic. Mixed infections are of common occurrence. The path of 
invasion is usually by way of the uterus ; seldom by the abdominal 
route from the ovary, bowel, and peritoneum. More rarely is the 
invasion by way of the lymph and blood streams. 

The manipulation of an infected uterus during the process of an 
examination or operation is doubtless often responsible for exten- 
sion of the infection from the uterus to the tubes. 

There are no pathognomonic symptoms of salpingitis, and none 
that are invariably present. Associated inflammatory lesions in 
the genital tract are nearly always found, and hence it is that the 
symptoms of the one are so intimately associated with those of 
the other, and, therefore, it is difficult to obtain a clinical picture 
of salpingitis. 

Again, the innervation of the tubes, ovaries, and uterus is so 
intimately connected as to bring these organs into close sympathy 
one with the other. 

Pain is the most constant symptom, and yet advanced cases of 
salpingitis exist in the absence of pain. Temperature has but little 
diagnostic value. Sterility does not necessarily follow as the result 



314 SPECIAL DIAGNOSIS. 

of double salpingitis. An occluded lumen may eventually become 
patent and permit the passage of the ovum. 

The history of infection and the clinical course of the disease 
cannot in themselves suffice for a diagnosis, but must be supported 
by direct palpation of the diseased tubes. 



CLASSIFICATION OF SALPINGITIS. 

I. Catarrhal Salpingitis. 

1. Acute catarrhal salpingitis (endosalpingitis). 

2. Chronic catarrhal salpingitis. 

a. Salpingitis isthmica nodosa. 
End stages : 

a. Hydrosalpinx. 

b. Hematosalpinx. 
II. Purulent Salpingitis. 

1. Acute suppurative salpingitis. 

a. Septic. 

1. Puerperal. 

2. Non-puerperal. 

b. Gonorrhoea!. 

2. Chronic suppurative salpingitis. 
End stage— Pyosalpinx. 

III. Tuberculous Salpingitis. 



I. CATARRHAL SALPINGITIS. 

Etiology. The statistics of Martin illustrate the frequency of 
the lesion. In 1402 operations on the tubes 415 (29.5 per cent.) 
were for catarrhal salpingitis. 

As a rule, the lesion is secondary to inflammatory diseases of the 
uterus, which extend by direct continuity of tissue. Primary 
catarrhal salpingitis, in the absence of an inflammatory lesion else- 
where in the pelvis, is an unusual occurrence. 

We may speak of the causes as thermic, mechanical, chemical, 
and microbic. 

1. Thermic influences resulting in salpingitis can scarcely act 
directly because of the deep-seated location of the tube. Menstrual 
congestion from chilling of the body may be placed in this category. 



THE DIAGNOSIS OF DISEASES OF THE TUBES. 315 

2. Mechanical causes have a greater significance. Such, for 
example, are digital and instrumental manipulations, sexual excesses, 
massage, and overstrain in lifting and walking. 

3. Chemical irritants in the form of antiseptics injected into the 
uterus may pass into the tubes and set up a salpingitis. 

4. By far the most essential and prevailing factors in the causa- 
tion of catarrhal salpingitis are the pathogenic micro-organisms. 

It is not always possible to distinguish between the above-named 
causes in a given case of catarrhal salpingitis. Two or more factors 
may operate to bring about the same result. Of the general dis- 
eases complicated by catarrhal salpingitis mention may be made of 
all the specific, infectious, and contagious diseases, notably tubercu- 
losis, malaria, and chlorosis. 

Anatomical Diagnosis. In acute catarrhal salpingitis the tube 
is of a livid or dark red color, is slightly thickened and convoluted, 
its consistency is increased to a limited degree, and the fimbria? are 
red, swollen, and retracted to a variable degree preparatory to a 
possible closure of the abdominal end of the tube. On cross-section 
of the tube the mucosa rolls out and is congested and thickened. 
In the lumen of the tube is a variable amount of serous fluid. No 
adhesions surround the tube. 

The microscopic diagnosis is based upon the marked congestion 
and infiltration with small round cells in the mucosa, and to a less 
degree in the musculature. Here and there are hemorrhagic extrav- 
asations into the connective tissue spaces. The epithelial lining 
of the tubular lumen may be normal, but in long-standing lesions 
the cells may degenerate and become desquamated. The secretion 
found in the lumen of the tube is in great part lymph mixed with 
blood cells and degenerated epithelium. From the acute stage the 
tube may easily resolve into a normal condition, suppuration may 
follow, or, as is not infrequently the case, the acute stage may pass 
into the chronic. 

In chronic catarrhal salpingitis the tube enlarges in all diameters 
and is correspondingly convoluted. The tube is of firmer consist- 
ency than in the acute stage. The mucosa and muscularis are 
thickened through congestion of the bloodvessels and hyperplasia 
of the connective tissue. The epithelium lining the tube lumen 
may be destroyed. Following this the lumen may be obliterated 
by adherence of the denuded mucous folds. Adjacent folds of 
mucous membrane may adhere by their free margins and lock in 



316 



SPECIAL DIAGNOSIS. 



spaces filled with a serous secretion and lined with columnar 
epithelium, thereby closely simulating retention cysts formed from 
glands. The mucous folds become club-shaped from congestion 
and the inflammatory exudate. The peritoneal covering of the 
tube is involved, and adhesions may surround the tube and close 
up the fimbriated end, leading to the formation of a hydrosalpinx. 
Salpingitis isthmica nodosa is regarded by Chiari and Schauta as 
a circumscribed interstitial salpingitis located in the isthmus of the 



Fig. 157. 















\ % *i£4 4 






■■ :■■■■■ v : . 
■ - :•-■■■ '. , 




lift - ' ^""^ ' ^ 


P%& 




|i "'' ; - : • ' ""'■ , : ' "'- : ^ 


- ■ ^1 






^V,'^x '^"^/^'i 




" •-. :-^. ......'.. • ' dsdw. V/ahRER, 



Catarrhal salpingitis. The villous projections of the mucosa are club-shaped, congested, and 
infiltrated with small round cells. The muscularis is congested. 



tube and forming a nodular enlargement varying in size from that 
of a split pea to a bean. Gebhard regards these growths as benign 
adenomata. 

Hydrosalpinx (sactosalpinx serosa) is the end stage of catarrhal 
salpingitis. The ends of the tube become closed and the pent-up 
secretion distends the tube into a serous sac. Because the thin, dis- 
tended, fimbriated end of the tube offers little resistance to the 



PLATE XXXVIII. 



■ ' -3 




••;. 



': -a **! 



M 



§CV4 






■ i*o 



^.1J^: , «5 



(^ 



W 









Ai**' 












s* 5 - 












Hydrosalpinx. 

A branching fold of mucous membrane projects into the lumen 
of the tube. It is composed of connective tissue covered by a single 
layer of columnar epithelium. A section of the tube wall is com- 
posed of connective tissue, muscle fibre, and bloodvessels ; and is 
lined within by a single layer of columnar epithelium. 



THE DIAGNOSIS OF DISEASES OF THE TUBES. 317 

accumulating fluid, the tube distends at the outer end to a far 
greater extent than at the uterine end, where the muscular wall is 
more resistant and the lumen of the tube smaller. It is unusual 
for the tube to distend throughout its entire length ; it may enlarge 
to the size of a child's head. The larger the tube the thinner and 
more transparent is the wall. 

Adhesions to the tube are not ordinarily present, and are seldom 
firm, hence hydrosalpinx is more or less movable. The fimbriated 
end is shaped like a club or retort. Radiating lines mark the 
adhesions of the fimbriae. 

In the early stage we have the gross and microscopic appearance 
of catarrhal salpingitis. As the tube distends the walls become 
thinner and more transparent ; the mucosa thins and the muscula- 
ture is stretched and atrophied, presenting longitudinal bands of 
muscle fibres running the entire length of the tube and terminating 
at the fimbriated end in a rosette figure. 

The epithelium of the mucosa is compressed and may be wholly 
lost. The contents of the tube is clear, serous fluid, with a specific 
gravity of 1005 to 1010, and an alkaline or neutral reaction. 
Sometimes the fluid is of a greenish tint, due to the presence of 
cholesterin. Desquamated epithelium, leucocytes, and occasionally 
a few red blood cells are found in the fluid contents of the tube. 

AVhen the uterine end of the tube is not permanently and com- 
pletely closed the contents may be periodically discharged into 
the uterus (hydrops tubce profluens). As expressed by Sutton, the 
blockade at the uterine end has been raised. 

The contents of the tube may be absorbed, but it is unusual for 
the fimbriated end to reopen. 

A pyosalpinx may develop from a hydrosalpinx by secondary 
infection with pyogenic organisms conveyed through the uterus or 
bowels. Tortion of a hydrosalpinx is a possible event leading to 
the formation of a hematosalpinx. 

Sutton gives the following reasons for believing that a pyosalpinx 
often resolves into a hydrosalpinx : 

1. Hydrosalpinx is not found in acute cases. 

2. In many chronic cases hydrosalpinx is found on one side of 
the uterus and pyosalpinx on the other. 

3. The ampulla of a tube will sometimes be dilated into a hydro- 
salpinx, while the isthmus contains pus. 

4. The fluid contents in a hydrosalpinx will sometimes be color- 



318 



SPECIAL DIAGNOSIS. 



less, but the recesses of the tube contain caseous material and 
cholesterin. 

5. The dilated tube in the hydrosalpinx may, as in pyosalpinx, 
communicate with a large ovarian follicle to form a tubo-ovarian 
cyst. 

Tubo-ovarian Cyst. Here the ovary is distended into a cyst which 
communicates with a hydrosalpinx through an adventitious open- 
ing. A congenital tubo-ovarian cyst has not as yet been described. 
As a rule, the hydrosalpinx and ovarian cyst develop independently. 

Fig. 158. 




Tubo-ovarian abscess. Abscess cavity in the ovary. (Dudley. 



Later the two structures unite by adhesions, the partition wall 
atrophies, gives way, and there is established a communication 
between the two. Rokitansky described a corpus luteum cyst 
communicating with a hydrosalpinx. 

The fimbriae of the tube may be found free in the ovarian cyst or 
adherent to the inner surface of the cyst wall. 

Hematosalpinx. From the macroscopic appearance it is not 
always possible to distinguish an inflammatory hematosalpinx from 
one due to ectopic pregnancy or to other non-inflammatory causes. 



THE DIAGNOSIS OF DISEASES OF THE TUBES. 319 

The wall of the tube is possibly thicker from round-cell infiltration 
and hyperplasia, and inflammatory adhesions may form about the 
tube. In addition there are usually evidences of infection in the 
uterus. A careful study of specimens of hsematosalpinx will, in a 
large percentage, lead to the discovery of an embryo, an apoplectic 
ovum, or chorionic villi. It is the uniform testimony of observers 
that nearly all cases of hsematosalpinx are due to ectopic gestation. 

The term hcematosalpinx should be reserved exclusively for 
Fallopian tubes dilated with blood and in which there is no evi- 
dence of pregnancy. A dilated tube containing chocolate colored 
fluid is not to be classed as hematosalpinx. 

The gross and microscopic appearances of hsematosalpinx do not 
differ greatly from those of hydrosalpinx, with the exception of the 
contents and the dark red color which is imparted to the contents. 
Fluctuation may not be so distinct in hsematosalpinx. 

Clinical Diagnosis of Catarrhal Salpingitis. 1. Acute Catar- 
rhal Salpingitis. The clinical picture is usually that of uterine 
catarrh or of acute pelvic inflammation. Rarely are the tubes 
alone involved, and hence it is difficult to clearly define the clinical 
signs of catarrhal salpingitis. There is a feeling of weight and 
discomfort in the pelvis, often amounting to acute pain, which is 
located in one or both sides. Painful urination and defecation are 
sometimes complained of. 

The initial chill, followed by a rise of temperature, which is 
accompanied by flashes of heat and cold, may be due to the sal- 
pingitis, but is more often the result of more extensive lesions in 
other parts of the pelvis. 

It is possible for catarrhal salpingitis to exist without the knowl- 
edge of the patient. 

The diagnosis must, therefore, rest largely upon the local findings, 
for in the absence of a physical examination no positive diagnosis 
can be made. Because of pain and tenderness the tubes cannot be 
palpated without an anaesthetic. The tube, as outlined in a bimanual 
examination, is about the size of the little finger ; it is movable, 
slightly more resistant to pressure than is the normal tube, and at 
the fimbriated end the sensation imparted is that of a soft, ill-defined 
mass. 

2. Chronic catarrhal salpingitis may arise in a very insidious 
manner, or may begin as an acute infection, with all the symptoms 
and signs above referred to. In the chronic stage there is no tern- 



320 



SPECIAL DIAGNOSIS. 



perature and no increase in the pulse rate. The patient is often 
nervous, and suffers from pain, particularly during the menstrual 
periods. Sexual intercourse is painful, and a leucorrhoeal discharge 
is a common accompaniment. 

In the form described by Chiari and Schauta, known as salpingitis 
isthmica nodosa, the pain during menstruation is colicky and cramp- 
ing. The tenderness on palpation is not so great as in the acute 
stage. The tube is outlined as irregular, convoluted, and of the 
size of the thumb or index finger. In consistency the tube is much 
firmer than normal, and in manipulating the tube the range of 
motion is observed to be restricted, in part from loss of flexibility, 
and in part from the presence of adhesions about the tube. The 



Fig. 159. 




Large hematosalpinx ; semidiagratnmatic. (Thomas and Munde.) 



position of the tubes is seldom exactly normal. More often they 
are found at the side of or behind the uterus. The uterus may be 
drawn to the affected side and restricted in its range of motion. 

In salpingitis isthmica nodosa the nodular swellings near the 
horn of the uterus are sometimes recognized in a bimanual examina- 
tion. Few cases have been diagnosed clinically. 

Hydrosalpinx and hematosalpinx are recognized clinically by 
the pressure they make upon the surrounding structures and by 
direct palpation. The patient may be wholly unaware of the 
existence of the lesion. 

In a conjoined examination, preferably under anaesthesia, the 
distended tube is outlined as a retort-shaped mass, tense, elastic, 
and often fluctuating. If no adhesions surround the tube there 



h 



PLATE XXXIX. 
m 









oi ov 

Figure 1. a, Salpingitis Catarrhalis Hemorrhagica, Cross Section, m, 
Muscle of the tube. n, Mucosa of trie tube. /, Lumen of the tube. Piero- 
earmine stain. ( Hartnaek, Oe. 2; Objective 4. ) b, Leucocytes containing 
blood pigment with normal red blood corpuscles from the tubal mucosa. 
(Hartnaek, Oe. 2; Objective 7.) 

Figure 2. Salpingitis Purulenta Acuta Dextra. ou, Uterine opening of tube. 
oa, Abdominal end of tube, ov, Right ovary. /, Purulo-fibrinous deposit. 
Posterior view, natural size. 

Figure 3. Salpingitis Purulenta Chronica Dextra. ou, Uterine end of tube. 
oa, Region of Abdominal end of tube, ov, Ovary with strongly adherent tube. 
Posterior view, natural size. l August Martin, Krankheiten der Eileiter. 



THE DIAGNOSIS OF DISEASES OF THE TUBES. 321 

should be a free range of motion. The small and firm uterine end, 
together with the outer, rounded, elastic, and fluctuating portion, 
gives the impression of an ovarian cyst. The ovary can rarely be 

Fig. 160. 




Right tubo-ovarian abscess and leit pyosalpinx. The right tube and ovary are distended 
with pus as is also the left tube. Adhesions bind the tubes together and the right tube to the 
posterior surface of the uterus, rectum, and wall of the pelvis. 

recognized apart from the distended tube. There is no way of 
detecting a hydrosalpinx from a hematosalpinx except by aspirating 
or by an exploratory incision. 

Tubo-ovarian cysts are only recognized after the cyst is removed. 

II. PURULENT SALPINGITIS. 

Etiology. The causes are essentially those of catarrhal salpingitis. 
As previously stated, catarrhal salpingitis may be followed by sup- 
puration. On one side may be a catarrhal salpingitis ; on the other 
side a purulent salpingitis ; the two apparently distinct and separate 
lesions may be dependent upon the same cause. 

Following are the statistics from the clinic of A. Martin : In 
2098 cases of purulent salpingitis, 279 were caused by gonorrhoea, 
374 by puerperal septic infection, 19 by tuberculosis, and 13 by 
syphilis. Of this number 1282 were preceded by catarrhal sal- 
pingitis. From the statistics of Martin, Schauta, Frommel, Char- 
rier, Wertheim, and Prochowick 376 cases are collected, and of 
this number, 76 showed a pure culture of the gonococcus, 10 a mixed 

21 



322 SPECIAL DIAGNOSIS. 

gonococcus infection, 15 a staphylococcus and streptococcus, 7 a 
pneumococcus, and 3 a bacterium coli infection. In 15 there was 
doubtful identity, and in 215 the tubes were sterile. 

In puerperal septic infection the essential causes are, in the order 
of frequency, staphylococcus pyogenes aureus and albus, and strep- 
tococcus pyogenes. The gonococcus, the tubercle, and colon bacilli 
are occasional factors. 

The infection commonly travels by direct continuity of tissue, 
passing directly from the endometrium to the tube. Occasionally 
the infection is conveyed through the broad ligaments to the tube, 
or from the peritoneum to the tube. 

Infection of the tubes acquired by instrumental and digital 
manipulations is due to the same sort of bacteria as are found in 
puerperal infection. 

Gonorrheal infection of the tube is for the most part acquired by 
sexual intercourse, but may be conveyed by instruments and the 
fingers both in the puerperal and non-puerperal state. The infec- 
tion usually travels by continuity of tissue, but may be conveyed 
by the lymph and blood streams. 

Anatomical Diagnosis, a. In acute purulent salpingitis there are 
all the evidences of an intense acute inflammation. The tube is 
enlarged possibly to the size of the thumb ; the color is an intense 
red ; the distended bloodvessels stand out prominently under the 
serous covering, and the fimbriae are swollen and retracted. Very 
early in the process the fimbriae may be agglutinated, thereby com- 
pletely closing the abdominal end of the tube. These adhesions 
are not firm, and for this reason the bimanual examination must 
be made cautiously for fear of expressing the pus from the tube into 
the abdominal cavity. From the naked-eye appearance of the 
unopened tube it is impossible to say whether or not there is pus 
within the lumen. 

In the acute stage a fresh fibrinous exudate forms about the 
tube, and as the lesion passes into the chronic stage these adhesions 
extend and become more firmly organized. The elongation of the 
tube leads to kinking and convolutions in the course ; the tube 
may be completely doubled upon itself. In the lumen of the tube 
pus is accumulated in varying amounts. 

Under the microscope the tubal wall is seen to be congested, and 
there is round-cell and leucocytic invasion of its entire wall. 
Pyogenic micro-organisms can be demonstrated throughout the 



THE DIAGNOSIS OF DISEASES OF THE TUBES. 323 

wall. The epithelium of the mucosa is early destroyed, and the 
folds of denuded mucous membrane adhere, thereby partially or 
completely obliterating the lumen of the tube and locking in spaces 
filled with pus. Throughout the muscularis and underneath the 
serous covering are localized areas of suppuration. In the pus 
accumulated in the lumen and wall of the tube it is often possible 

Fig. 161. 



■'.<: "^ ^-F^V -> / •-" "-- ■ .'" 'vv ■-:':" ''' ' * * '' 




&'\ -''*'-': ' " H'jT -i.-. <--'-s / \'' : C - : : ' ''• "1 ..:.: " 


y^& ''-''--'* ': i; %%j 


> '>v"'.\:;v ..••?/!•■.": •....'■ *",>7'"."» '": „• ■ '■v.( 1 ~ ) ; : -:-■ ' ,V :.<>.■-''.- •.'- 


-'.".' • ■ .*. • « ' ji ' >**"* 




'' . ■ ;; ; .' •>" T .■■ 








- > -^. : ; - 




*'*: i-'^":'. ; "*-' ""' 




■., .S" i ■-'' 


. .- r '..: .'' v ."' . '*.' *' %- •.'\ B ' '■»'* 




: Mj|5v^,, v . \, ,;*..*,,, • : 0*£*§* 


v. >fi-j'v- «► ■ ^.' 






';'^-:v'.V'^^';''. V/':~ :.,•■• •>' •'-••"'li '.. ": : ' 'v - '^ 


6^ ■ .*" 


^•>.>. ■. ''■-.- • .-.«.'. — .■'"■ 


•'V "i*,** 






•• .^rf' 







Acute purulent salpingitis The folds of mucous membrane are swollen and club-shaped ; 
they are infiltrated with small round cells, pus cells, and pyogenic micro-organisms. A similar 
infiltration is found in the muscularis. In the lumen of the tube is found blood and pus cells 
in all stages of degeneration. The epithelium is intact. 

to demonstrate the presence of the micro-organisms causing the 
infection. The older the infection the less likely is the finding of 
bacteria. There may be superficial necrosis of the mucosa forming 
a pseudodiphtheritic membrane. Gonorrheal infection is more 
likely to be coufined to the mucous membrane than are the other 
forms. Wertheim demonstrated the presence of the gonococcus in 
all portions of the tube. 



324 SPECIAL DIAGNOSIS. 

b. In chronic purulent salpingitis the tube attains to about the size 
of the thumb. The color is not such an intense red as in the acute 
stage, and the adhesions are firmer and more extensive. The fimbriae 
are almost invariably adherent, obliterating the abdominal end of 
the tube. The convolutions of the tube are bound one to another, 
and are adherent to the ovary, uterus, bowel, bladder, omentum, 
and abdominal wall. These adhesions permit very limited excur- 
sions of the tube. As the tube enlarges and the adhesions contract 
the tube and ovary adhere to the side of or behind the uterus. The 
appendix vermiformis and tube are so frequently adherent that it is 
always advisable to inspect the appendix when the abdomen is 
opened. From the tube the pus may evacuate through adhesions 

Fig. 162. 




Double pyosalpinx with uterine adhesions. (Bandl.) 

into an adherent hollow viscus. Again, the infection may travel 
from the bowel through the adhesions to the tube and cause a 
secondary infection in the tube. 

The pus within the tube is yellow or grayish-yellow, rarely greenish 
or blood-stained. Nothing can be ascertained from the naked-eye 
appearance of the pus as to its virulence. In long-standing cases 
the formed elements of the pus may absorb, leaving a serous fluid. 

The entire wall of the tube is thickened through congestion and 
hyperplasia of the connective tissue. Small abscesses may be seen 
in the mucosa, the muscularis, and underneath the serosa. 

Pyosalpinx (sactosalpinx purulenta). Where the ends of the tubes 
are closed the pus accumulates within the lumen and distends the 



THE DIAGNOSIS OF DISEASES OF THE TUBES. 



325 



tube. The greater distention is at the fimbriated end, where the 
wall is thin. It is seldom that the tube is distended throughout 
its entire length. The size is seldom greater than a man's fist, but 
it may be large enough to extend above the brim of the pelvis and 
even to the umbilicus. The wall of the tube is at first thickened, but 
when greatly enlarged there is an irregular thinning, even to the 
point of rupture. Rupture of the tube may take place at its lower 
circumference between the layers of the broad ligament or at any 
point in the wall of the tube. Adhesions usually protect the peri- 
toneal cavity, and frequently direct the pus into a hollow viscus or 
into a cyst of the ovary. Left pyosalpinx is very prone to rupture 
into the rectum. 



Fig. 163. 




The left tube is distended with pus and is adherent to the posterior surface of the uterus. 
The right tube and ovary are normal. 



The pus contained within the distended tube is found in various 
stages of preservation, and is mixed with red blood cells, degen- 
erated epithelium, fibrin, and detritus. The mucosa atrophies from 
pressure, and may be replaced by connective tissue. The epithelium 
is almost wholly destroyed. The muscle and connective tissue 
fibres are atrophied and the bloodvessels are limited in number. 

The Clinical Diagnosis of Purulent Salpingitis. 1. Acute 
purulent salpingitis is generally ushered in by marked constitutional 
disturbances. There may be an initial chill ; this is followed by 
a rise of temperature and pain referred to the affected tube. In 



326 SPECIAL DIAGNOSIS. 

nearly every instance there is a similar lesion in the uterus, which 
may mask the more limited affection of the tube. Very often the 
infection does not stop in the tubes, but is carried on to the ovaries 
and peritoneum, giving rise to additional temperature and pain that 
will wholly mask the clinical manifestations of the affected tube. 
As a rule, the tubes are not involved for from three to five days fol- 
lowing septic infection of the uterus. After complete resolution in 
the uterus and peritoneum the infected tube may fail to resolve, and 
remain distended with pus. This indisposition on the part of the 
tubes to resolve as readily as do other parts of the genital tract is 
explained in part by the lessened power of absorption in the tube, 
but in greater part by the closure of the ends of the tube, thereby 
locking in the pus. 

Repeated exacerbations are the rule. These are brought about 
by sexual excesses, menstrual congestion, and injudicious exercise. 

We seldom find gonorrhoeal infection invading the tubes before 
the second or third week after the initial infection of the cervix. 
As a rule, the general symptoms are not so well-marked in gonor- 
rhoeal infection as in other forms of septic infection. 

2 . Chronic purulent salpingitis usually begins with an acute attack 
and ends in a pyosalpinx. The general disturbances are in nowise 
proportionate to the extent of the lesion. All symptoms may be 
absent in the presence of an extensive lesion. Menstrual disorders 
in the form of a menorrhagia and dysmenorrhea are fairly constant 
symptoms. Pain in the region of the tubes and referred to the back 
and thighs, together with digestive disorders, are common com- 
plaints. Sterility is almost sure to result from a bilateral involve- 
ment of the tubes. Martin reports three cases of bilateral pyogenic 
infection of the tubes in which pregnancy followed. 

Palpation of the diseased tubes can usually be accomplished 
without difficulty. When found impossible to clearly outline the 
tubes an anaesthetic should be given. The uterus is first located. 
It is seldom found in the median line, and its range of mobility is 
restricted. The tubes are engaged between the examining fingers, 
and are traced outward from the horns of the uterus or downward and 
backward beside and behind the uterus. They are felt as sensitive 
thickened cords varying in consistency, size, position, and degree of 
mobility. The consistency is always firm at the uterine, less so at 
the fimbriated end. The kinks in the tube are felt as nodules in 
its course. Sensitiveness to pressure is directly proportionate to 



THE DIAGNOSIS OF DISEASES OF THE TUBES. 327 

the acuity of the inflammation. The ovary can be palpated apart 
from the tube only in exceptional cases. The position of the tube 
largely depends upon the position of the uterus. In retroposition 
the tubes and ovaries may lie in the pouch of Douglas. With the 
uterus erect and forward, it is scarcely possible for the tubes to 
reach into the pouch of Douglas. There will be no fluctuation 
unless the tubes contain a considerable amount of pus. 

The walls of a pyosalpinx are thicker and more resisting to the 
pressure of the contained fluid ; hence the tube is rarely so large as 
a hydrosalpinx may become. Furthermore, fluctuation is less 
marked, and there is greater fixity and sensitiveness to pressure. 

The character of the pyosalpinx should be determined when pos- 
sible — that is, whether due to gonorrhoea, puerperal infection, 
tuberculosis, or non-puerperal septic causes. 

The clinical history will often lead to a positive diagnosis, par- 
ticularly in gonorrheal and puerperal cases. Gonorrhoea is assumed 
to be the cause when other possible factors are eliminated. 

The presence of a purulent discharge from the urethra and infec- 
tion of the glands of Bartholin will determine the diagnosis of 
gonorrhoea! salpingitis to a moral certainty. Absolute certainty in 
the diagnosis is only obtained by the finding of the gonococcus of 
Neisser in the secretion. 

THE DIAGNOSIS OF SACTOSALPINX. 

The term sactosalpinx is understood to be a Fallopian tube dis- 
tended with fluid — i. e., blood, serum, or pus. Under the generic 
term sactosalpinx Ave place hsematosalpinx, hydrosalpinx, and pyo- 
salpinx — the end stages of catarrhal and purulent salpingitis. The 
following features are characteristic of sactosalpinx : 

The position is at the side of or behind the uterus, extending from 
the horn of the uterus outward or downward. Unless greatly dis- 
tended the tube lies below the normal level, most often close to the 
side of the uterus or immediately behind. 

The consistency is so variable as to render it of little value in 
diagnosis. When fluctuation is present it is of some diagnostic 
significance, but it is so often absent that it cannot be relied upon. 

The general contour is significant. We commonly speak of sacto- 
salpinx as being of retort- or sausage-shape. The tube is distorted 
in proportion to the degree of distention. The irregularity in the 
course of the tube can usually be noted in a bimanual examination. 



328 



SPECIAL DIAGNOSIS. 



The tube may be so snugly twisted upon itself as to give to the 
examining finger the impression of a round or oval swelling. So 
firmly may the tube adhere to the uterus the two are felt as a single 
mass. The outline of the tube may be lost in a surrounding inflam- 
matory exudate. 

The Diagnosis of the Contents of a Sactosalpinx. Following 
the recognition of a sactosalpinx it is next important to determine 
the contents of the distended tube. This can only be done with 
certainty by an exploratory puncture through the vagina or by an 
exploratory incision. The danger of carrying infection into the 
tube by the exploring-needle is not to be disregarded. Fortunately 
the indications for such a procedure are limited, because whether 
blood, pus, or serum, an operative procedure is indicated. 

Differential Diagnosis. Kelly gives the following differential 
diagnosis between gonorrheal and streptococcic infection of the 
tubes : 



GONORRHEAL INFECTION. 

1. Slow in its onset, often preceded by in- 

flammation of the external genitals and 
urethra. 

2. Pain localized in one or both ovarian re- 

gions. 

3. No signs of general peritonitis. 

4. Suffers more or less constantly, but may 

have no fever. 

5. Temperature 98.5° to 102° F. (38.9° C). 

6. Pulse accelerated, but of good quality. 

7. Attack lasts from five to fifteen days. 

8. Often presents the appearance of good 

health. 

9. Gonococci usually found on cover-slip 

preparation from the cervical, urethral, 
or vulvovaginal glandular secretions. 
10. History of marital gonorrhoea. 



Streptococcus Infection. 

1. Onset abrupt, following miscarriage, nor- 

mal labor, or topical applications. 

2. Pain more general and severe in the lower 

abdomen. 

3. Usually signs of peritonitis. 

4. Suffers constantly, and usually has a peptic 

fever. 

5. Temperature 101° to 105° F.(38.3° to 40.5° C.) 

6. Pulse never feeble and more rapid. 

7. Attack seldom lasts less than a month, and 

may continue three months or more. 

8. Anaemic and weak. 

9. Gonococci not found in the secretions. 



10. Husband sound. 



Appendicitis. 
1. No previous local disturbances. 



2. Chill usually absent. 

3. Pain in right iliac region, sudden onset, 

acute, and not radiating to thighs. 

4. Fever of variable degree. 

5. Muscular rigidity on right side of the 

abdomen. 

G. Inflammatory exudate about appendix 
three to five days after onset of symp- 
toms. 

7. Vaginal examination is rarely painful in 
appendicitis. 



Tubo-ovarian Disease. 

1. Geni to-urinary functions previously dis- 

turbed. Usually a history of gonorrhoeal 
or puerperal infection. 

2. Chill may precede fever. 

3. Gradual onset, pain dull, continuous, and 

radiating. 

4. Fever often entirely absent. 

5. No muscular rigidity unless complicated 

by peritonitis. 

6. Inflammatory exudate in the pelvis felt 

by vaginal examination at the onset of 
the symptoms. 
7. Always painful in tubo-ovarian disease. 



THE DIAGNOSIS OF DISEASES OF THE TUBES. 329 

Krussen says the appendix is involved in 15 per cent, of cases 
of tubo-ovarian disease. 

Martin found appendicitis complicating right-sided salpingitis 
thirteen times in 276 cases. Ochsner, in 51 cases of appendicitis, 
found the tube and ovary involved fifteen times. Because of the 
frequency with which appendicitis and salpingitis are associated an 
inflammatory lesion in the right side of the pelvis should suggest a 
possible involvement of both of these structures, and no operation 
is complete on either of these structures without investigating the 
condition of the other. It is possible for a primary appendicitis to 
extend to the rectocsccal connective tissue and on to the pelvic 
connective tissue, giving rise to a secondary parametritis. A 
similar extension may take place along the peritoneum from the 
caecum to the tubes and ovaries. The history of the onset and 
previous complaints are important considerations. Next in point 
of importance is the position of the swelling. Tumefactions in 
and about the tube are intimately connected with the uterus, and 
can be traced to its horn. In appendicitis the swelling is high up 
in the right iliac space, and in enlarging it extends downward into 
the pelvis in contrast to the swellings of tubo-ovarian diseases, 
which extend upward from the pelvis. In appendicitis it may be 
possible to palpate the tube and ovary apart from the exudate about 
the appendix. 

A subserous fibroid may be simulated by a pyosalpinx when the 
tube is round, thick-walled, closely adherent to the uterus, and 
surrounded by a firm, sharply-defined exudate. 

The clinical history is important. In pyosalpinx there is a his- 
tory of infection, either puerperal or gonorrheal, while in fibroids 
no such history is obtainable. In subserous fibroids the tumor is 
round, sharply circumscribed, not tender to pressure, usually freely 
movable, and unilateral. In pyosalpinx the tumor is more elon- 
gated, less sharply defined, tender to pressure, immovable, and 
often bilateral. In pyosalpinx there are evidences of infection in 
the lower genital tract, while with fibroids such is not the case. 

Parametric exudates are often associated with pyosalpinx, and 
their differentiation may be impossible. The location and general 
contour are the distinguishing features. The onset and general 
clinical manifestations closely simulate each other. 

A pyosalpinx is often bilateral, while a parametric exudate is 
commonly unilateral. The former lies on a higher level at the side 



330 SPECIAL DIAGNOSIS. 

of or behind the uterus, while the latter lies low in the pelvis in direct 
contact with the vault of the vagina, running from the sides of the 
uterus directly outward. A pyosalpinx is more sharply circum- 
scribed and is retort- or sausage-shaped. A parametric exudate is 
ill-defined. 

Ovarian and parovarian cysts may closely resemble a hydrosal- 
pinx. The diagnosis may be reserved for an exploratory incision. 
Hydrosalpinx is more often bilateral and elongated, and is more 
limited in size. 

New formations of the tubes are very rare as compared with 
inflammatory lesions. The presence of ascites associated with tubal 
swellings speaks in favor of malignant new formations of the tubes. 
For the differential diagnosis of salpingitis from tubal pregnancy, 
see Chapter XVII. 

TUBERCULOUS SALPINGITIS. 

Etiology. In this country our knowledge of tuberculosis of the 
tubes is largely contributed to by Williams, Penrose, and Edebohls. 

The following statistics are from Veit : 

Wenkel found tuberculosis five times in 575 cases. 

Donhoff found tuberculosis fourteen times in 509 cases. 

Schramm found tuberculosis thirty-four times in 3389 cases. 

Rosthorn found tuberculosis twice in 40 cases. 

Williams found tuberculosis seven times in 91 cases. 

Martin found tuberculosis seventeen times in 620 cases. 

The above constitute a sum total of 79 in 5224 cases, or 1 case 
of tuberculous salpingitis in 66 abdominal sections. 

Kundrat, in 140 abdominal sections for the removal of diseased 
uterine appendages, found tuberculous salpingitis in 4 cases and 
tuberculous endometritis in a single case. 

Williams is undoubtedly correct in his statement that tuberculosis 
often goes unrecognized in a catarrhal or suppurative salpingitis for 
want of microscopic and bacteriologic examinations. 

In two years' time at the Johns Hopkins Hospital the tubes re- 
moved for inflammatory lesions were found tuberculous in 8 per cent. 

The great frequency of genital tuberculosis as a primary lesion in 
the tubes is shown in the statistics of W. Meyer, who reports 67 
cases of primary tuberculosis of the genital tract, of which 57 were 
primary in the tubes. 



THE DIAGNOSIS OF DISEASES OF THE TUBES. 331 

We recognize a primary and secondary tuberculous salpingitis, 
Hegar, in his monograph of 1886, speaks of ascending and descend- 
ing infections. The ascending form may be primary or secondary. 
The descending is always secondary. 

The avenues by which the tubercle bacillus gains 
access to the tubes are : 

1. By the blood current (metastatic invasion), as found in sec- 
ondary involvement of the tubes from a primary focus in the lungs 
in the absence of a tuberculous lesion in the omentum, mesenteric 
glands, peritoneum, or bowel. 

2. By continuity of tissue either from the peritoneum or the 
uterus. In 194 cases of secondary tuberculous salpingitis the peri- 
toneum was primarily involved 110 times (Meyer.) When the 
tube is adherent to the bowel at the site of a tuberculous ulcer the 
infection may pass directly from the bowel to the tube without 
involving the peritoneum. Such infections are usually mixed with 
the colon bacillus. 

Emmet described a case in which the tubercle bacillus travelled 
from the uterus through the tube and attacked the peritoneum, 
leaving the tube free. 

3. By w r ay of the lymph current. In this manner tuberculosis 
may be conveyed from the lower genital tract through the broad 
ligaments without passing through the uterus. 

The infection is conveyed to the genital tract by the examining 
fingers, instruments, and coitus. Tuberculosis may be conveyed 
from the husband to the genital organs of the wife, even though 
his sexual organs are normal. 

The infection may travel direct to the tubes without attacking 
the uterus, vagina, or vulva. 

As predisposing causes may be mentioned age, the puerperium, 
and inflammatory lesions of the tubes. Tuberculous salpingitis 
may be found at any period of life from infancy to old age, the 
greatest number occurring from fifteen to thirty years of age. The 
age limits are wider than in any of the other forms of tuberculosis. 
The puerperal uterus, and particularly the placental site, is espe- 
cially susceptible to tubercular infection. 

Inflammatory lesions of the tubes are likely to have tuberculosis 
engrafted upon them. In this manner we have mixed infections of 
the tubercle bacillus with the gonococcus, staphylococcus, strepto- 
coccus, and colon bacillus. 



332 SPECIAL DIAGNOSIS. 

Anatomical Diagnosis. As in other forms of salpingitis, we 
recognize an acute and a chronic stage. 

Acute tuberculous salpingitis is very rare. The tube resembles 
the catarrhal form. There is a slight increase in the size of the 
tube together with marked congestion ; the mucosa is swollen and 
the secretion increased. The entire wall of the tube is infiltrated 
with small round cells, and in addition to these changes, which are 
those of acute catarrhal salpingitis, giant cells, tubercles, and tubercle 
bacilli are found in the mucosa and to a lesser degree in the nius- 
cularis. The lesion is more pronounced in the fimbriated end. The 
secretion collected in the lumen may be serous, bloody, or puru- 
lent. 

From the acute the lesion may merge into a chronic stage closely 
resembling chronic catarrhal or chronic suppurative salpingitis. 
As a rule, there is no acute stage. 

Miliary tubercles may aggregate to form large tubercles and 
nodules, which in turn may undergo caseous degeneration. The 
lumen of the tube may be filled with caseous material. A tuber- 
culous pyosalpinx may form after the closure of either end of the 
tube. 

There is no way of distinguishing tuberculosis of the tubes either 
in the acute or chronic stage from catarrhal or suppurative salpin- 
gitis except by the discovery of tubercles, giant cells, or tubercle 
bacilli. For this reason tuberculosis in a tube is often overlooked. 

Gray or yellowish-gray tubercles ranging in size from a miliary 
tubercle to a hazelnut, may be seen on the surface of the tube and 
on the peritoneum near by. Adhesions about the tube are usually 
firm and extensive. 

Williams describes a chronic fibroid tuberculous salpingitis in 
which there is a marked fibrous hyperplasia in and between the 
tubercles. Caseous degeneration is absent. This is a very chronic 
form, and may be regarded as a healing process. 

Calcification of the tuberculous product is described by Klob, 
Penrose, and Rokitansky. 

Clinical Diagnosis. Tuberculous salpingitis may be suspected 
when one or both tubes are found to be enlarged and tender to 
pressure, and the possibility of gonorrheal or puerperal infection 
can be excluded. The presence of tuberculosis elsewhere in the 
body or in the husband, and a tuberculous family history, will speak 
for tuberculosis as the cause of the lesion in the tube. 



THE DIAGNOSIS OF DISEASES OF THE TUBES. 333 

In primary tuberculous salpingitis the symptom of greatest 
clinical importance is prolonged and painful menstruation. 

The functions of the bowels and rectum are frequently disturbed. 

Abdominal ascites is found in about 15 per cent, of cases. An 
evening rise of temperature and increase in the pulse rate are 
significant. As a diagnostic test tuberculin may be administered. 

The local findings do not differ at first from those of acute and 
chronic salpingitis. Later nodules may be felt on the surface of the 
tube. There is nothing in the conjoined examination to positively 
identify a tuberculous tube. 

Hegar lays great stress upon the peculiar condition of the middle 
third of the tube, which presents firm, nodular swellings. In the 

Fig. 164. 




Tuberculous Fallopian tube. (Dudley.). 

absence of peritonitis there are no findings differing materially from 
those of salpingitis in general. The finding of tuberculous peri- 
tonitis naturally suggests tuberculosis of the tubes. An exploratory 
curettage may disclose tubercles in the scrapings. 

In favor of tuberculous salpingitis the following data may be 
given : 

1. The diagnosis of chronic salpingitis. 

2. Tuberculous lesions elsewhere in the body. 

3. Tuberculosis in the husband, particularly when involving the 
sexual organs. 

4. Family history of tuberculosis. 

5. Salpingitis in virgins (90 per cent, are said to be tuberculous). 



334 SPECIAL DIAGNOSIS. 

6. Tubercle bacilli in the leucorrhoeal discharge or in scrapings 
from the uterus. 

7. Ascites. 

SYPHILIS OF THE FALLOPIAN TUBE. 

Literature on syphilis of the tube is scant and cases are of rare 
occurrence. Three authentic cases are described by Ballentyne and 
Williams, Donhoff, Bouchard, and Lepine. 

Donhoff discovered the usual changes of catarrhal salpingitis in 
a* postmortem examination of a baby, nine days old, which had 
died of syphilis. 

The case recorded by Ballentyne and Williams was a seven 
months 7 child. There were numerous small gummata scattered 
throughout the tube wall and obliterating the lumen. 

Buchard and Lepine reported a case, aged forty years. Death 
was from syphilis. There was a gumma in each tube the size of a 
hazelnut, and the lumina of the tubes were occluded. 

ACTINOMYCOSIS OF THE FALLOPIAN TUBE. 

We know little of actinomycosis of the tubes. Zemann, Stewart, 
Muer, and Granger have contributed all that is now known. In 
the reported cases the lesion was both primary and secondary in 
the tubes. 

PARASITES OF THE FALLOPIAN TUBE. 

Echinococci have been found in the tubes, the infection being 
secondary to that of the abdominal viscera, the pelvic bones, and the 
paraproctal connective tissue. Benoit reported 80 cases found in 
the literature. 

NEW FORMATIONS OF THE FALLOPIAN TUBES. 

All new formations of the Fallopian tubes are of rare occurrence. 

Those described are : papilloma, polyp, myoma, fibroma, dermoid 
cyst, lipoma, fibromyxoma, cystoma, sarcoma, carcinoma, endothe- 
lioma, syncytioma malignum. 

1. Papilloma arises from the endosalpinx. Sanger was able to 
collect only six cases in the literature. Simple papilloma takes the 
form of a villous or cauliflower growth which may fill and distend 



THE DIAGNOSIS OF DISEASES OF THE TUBES. 



335 



thie tube. The villosities may adhere and lock in cystic spaces. 
The growth is histologically constructed of connective tissue cov- 
ered by a single layer of columnar epithelium, having no disposition 
to invade the connective tissue, as is the case in malignant papilloma. 
Metastasis does not occur. It has been suggested by Doran that 
benign papillary growths are of inflammatory origin. He bases his 
opinion on a certain, definite inflammatory reaction seen to accom- 
pany the growth. He believes gonorrhoea to be a potent factor. 

2. Polyps of the tube are virtually inflammatory lesions. They 
are rarely found. 

Fig. 165. 




Fibroniyxoma firnbriarum tub* cystosum. (Martin.) 
U. Uterus. Td. Right tube. Od. Right ovary. Ts. Left ovary. Its. Left infundibulum of 
the tube. Os. Left ovary. T\I. Pedunculated tumor. T.JI. Pedunculated tumor. T 3 . Sec- 
ondary pedunculated tumor. Ov. Calcareous body resembling an ovary. X. Cyst containing 
dark yellow fluid. Y. Gelatinous tissue without cavities. I. Blood cysts with blood detritus. 
II. Blood cyst with fresh blood III. Soft myxomatous tumor. IT'. Soft myxomatous tumor. 



3 and 4. Myoma and fibroma of the tube are not to be mistaken 
for the nodular swellings of salpingitis isthmica nodosa. Five cases 
are reported by Sanger. Bland Sutton reported one the size of an 
orange. V. Recklinghausen reported an adenomyoma of the tube 
arising from the duct of M tiller. 

5. Dermoid cysts of the tube are described by Pozzi and Richie. 

6. Lipomata are not of such unusual occurrence in the tube. 
They are usually located between the two layers of the meso- 
salpinx, and have been known to attain the size of a hen's egg. 



336 SPECIAL DIAGNOSIS. 

7. Fibromyxoma cystoma of the fimbriae was described by Sanger 
(Fig. 165). There were three tumors connected by fimbriae to a 
normal tube. They consisted of fibrous and myxomatous tissue. 

8. Sarcoma of the tube has a papillary structure that cannot be 
distinguished from benign papilloma or carcinoma by the naked 
eye. But five cases are recorded. 

9. Carcinoma of the Fallopian tube may be primary or secondary. 
Orthmann was the first to describe primary carcinoma of the tube. 
Like other new formations of the tube, carcinoma assumes a 
papillary form, and in its histological structure is not unlike 
papillary adenoma of the ovary and malignant adenoma of the 
uterus. Secondary carcinoma of the tube resembles the primary 
growth, and is an extension from a similar growth in the uterus and 
tubes. One-third of the primary carcinomata of the ovary extend 
to the tube. 

It has been repeatedly observed that inflammatory lesions of the 
tubes serve as forerunners of carcinoma. 

Le Count 1 says : " It is especially concerning tumors of the 
Fallopian tube that confusion has arisen ; there has been quite a 
general failure to recognize that a diffuse hyperplastic inflammation 
is possible — a process that is strictly analogous to the polypous 
hyperplasia of other mucous surfaces — and that in certain typical 
examples it is as distinct from tumor growth as gastritis proliferans 
is from carcinoma of the stomach." He believes it fully demon- 
strated that there exists an imperceptible transition of hyperplastic 
processes of the tubal mucosa into those of true tumor growth, and 
that these may terminate in the production of benign tumors and 
then into a malignant new formation. 

We find carcinoma of the tubes occurring about the time of the 
menopause — a time when inflammatory lesions are less frequent. 

Sanger-Barth observed a direct malignant degeneration of the tubal 
mucosa. Doran and Fearne observed a malignant transformation 
in a benign papilloma. 

Carcinoma of the Fallopian tube is commonly unilateral. Accord- 
ing to Sanger-Barth, it usually arises from the middle and outer 
portions of the tube. 

In conformity with many authors we will recognize two micro- 
scopic forms — the papillary and the alveolar. 

1 The Genesis of Carcinoma of the Fallopian Tube in Hyperplastic Salpingitis, with a Report 
of a Case and a Table of Twenty-one Reported Cases. Johns Hopkins Bulletin, March, 1901. 



THE DIAGNOSIS OF DISEASES OF THE TUBES. 337 

The papillary form consists of numerous papillae composed of 
connective tissue and covered by columnar epithelium. 

Alveolar carcinoma of the tube shows a greater proliferation of 
the epithelium and the grouping of these epithelial elements into 
nests. 

CYSTIC NEW FORMATIONS OF THE FALLOPIAN TUBES. 

Hydatids of Morgagni are transparent cysts containing a clear, 
watery fluid. They are found on the peritoneal covering of the 
tube and broad ligament, either isolated or arranged in groups. 
The fimbriae of the tube may distend with a similar fluid and 
present the appearance of cysts of Morgagni. 

Cysts as large as a walnut have been found in the mucosa of the 
tube, and are inclusions of the mucous folds. 

Cysts of equal size are found in the musculature. These arise 
from the ducts of Gartner. 

The following classification is from Sanger : 

1. Serous cysts, lying beneath the serous covering of the tube 
and varying in size to a child's head. 

2. Lymphangiectasis. 

a. As small cysts on the tube and ligament. 

6. Winding canals or cysts located under or within the 

peritoneum of the tube and broad ligament. 
c. Lymphangiectatic cysts, large and isolated, located in the 

subserosa of the tube and in the mesosalpinx. 

3. Hydatids of Morgagni, which are to be regarded as physiolog- 
ical, and are located in the fimbriae. 



22 



CHAPTEE XXIX. 

THE DIAGNOSIS OF THE DISEASES OF THE OVARIES. 

Normal Anatomy of the Ovary. The ovaries are two in 
number, lying behind the broad ligaments on a level with the brim 
of the pelvis, midway between the horn of the uterus and the psoas 
muscle. The ovary is oval in shape and about the size of an 
almond. The average measurements, as given by Farre, are : 
Longitudinal diameter, one-third of an inch ; transverse diameter, 
three-quarters of an inch ; perpendicular diameter, three-eighths of 
an inch. The anterior border (hilum) is flat, and is attached to the 
broad ligament ; the posterior border is convex and free. The 
ovary lies in a shallow concavity formed by the posterior layer of 
the broad ligament. This fossa of the broad ligament is a remnant 
of the peritoneal pouch in which the ovary of the rat and other 
mammalians is enclosed. Such a fossa was observed in a case by 
J. Clarence Webster. 

The ligaments of the ovary are two in number — the ovarian 
ligament and the infundibulo-pelvic ligament. In addition to these 
ligaments the ovary is attached at its hilum or anterior border to 
the posterior layer of the broad ligament. The infundibulo-pelvic 
ligament connects the outer end of the Fallopian tube to the side 
wall of the pelvis, and may be regarded as that portion of the upper 
border of the broad ligament not occupied by the Fallopian tube. 
It is about 2 cm. in length. 

The ovarian ligament extends from the horn of the uterus to the 
inner end of the ovary, and is about 3 c.cm. long. 

THE HISTOLOGY OF THE OVARY. 

The ovary is covered with a layer of nucleated columnar cells 
continuous at the hilum with the peritoneal endothelium. At the 
point of transition is a white, glistening line called the " white line 
of Farre." The epithelium covering the ovary is called the " germ 
epithelium of Waldeyer," and beneath it is a fibrous layer known 
as the tunica albuginea. 



THE DIAGNOSIS OF DISEASES OF THE OVARIES. 339 

The framework of the ovary is of connective tissue, and is divided 
into cortical and medullary portions, the former lying external to 
the latter. The Graafian follicles are scattered throughout the 
ovary. Nerves, bloodvessels, lymphatics, and muscular fibres are 
also found in the connective tissue. The medullary portion is 
more vascular than the cortex. 



Fig. 166. 




13 G a r t n e r s Duct 



v A R o VA n j v 



K 



fit 




p 
o 

■s 



Cyst-producing region of the ovary and its surroundings. (Dudley). 
A. Uterus, Fallopian tube, parovarium, and ovary. B. Gartner's duct, parovarium, and 
ovary shown in section; p, paroophoron, sometimes called the vascular or medullary zone; 
o, oophoron, this is the egg-bearing portion, sometimes called parenchymatous zone, some- 
times the cortical portion ; s, free external surface of ovary ; k, Kobelt's tubes. 

The Graafian follicles number 40,000 to 70,000 in the infant 
ovary. They vary in size from one one-hundredth to one- 
thirtieth of an inch in diameter. The younger and smaller follicles 
occupy the medullary portion, and as they grow larger they are 



340 



SPECIAL DIAGNOSIS. 



found to occupy the cortical portion. A Graafian follicle con- 
sists of : 

1 . A tunica fibrosa and membrana propria. 

2. The membrana granulosa and discus proligerus. 

3. The liquor folliculi. 

4. The ovum surrounded by the discus proligerus and composed 
of: 

<x. Zona pellucida, a homogeneous external membrane. 

b. Yolk protoplasm. 

c. Germinal vesicle. 

d. Germinal spot. 

Methods of Examination. The bladder and rectum should be 
empty, and all restricting clothing removed from the waist. An 

Fig. 167. 




Section of the ovary. (After Schron.) 
1. Outer covering. V. Attached border. 2. Central stroma. 3. Peripheral stroma 4. Blood- 
vessels. 5. Graafian follicles in their earliest stage. 6, 7, 8. More advanced follicles. 9. An 
almost mature follicle. 9'. Follicle from which the ovum has escaped. 10. Corpus luteum. 



anaesthetic is not always required, but is helpful in all cases and 
indispensable in many. The patient is placed in the lithotomy 
position. The abdomino-vaginal method is usually chosen. If the 
vagina is short, resisting, or sensitive to pressure, or if the hymen 
is intact, it will be advisable to make a recto-abdominal examination. 
When the ovary lies behind the uterus it may be better palpated 
through the rectum. 

As a matter of routine, it is advisable to first locate the uterus, 
then follow from the horn of the uterus along the course of the tube 
to the ovary. The right ovary is best detected by the finger of the 
right hand in the vagina and the left ovary by the finger of the 



THE DIAGNOSIS OF DISEASES OF THE OVARIES. 341 

left hand. It is not, as a rule, necessary to change hands ; either 
the right or the left hand will suffice in most cases for the exam- 
ination of both ovaries. 

In difficult cases Ulmann recommends filling the rectum with a 
colpeurynter to force the ovary upward and forward within easier 
reach of the examining finger. 

ANOMALIES IN THE DEVELOPMENT OF THE OVARY. 

1. Absence of one or both ovaries may occur as a congenital 
defect, or the entire ovarian tissue may be completely lost through 
atrophic changes and new formations. When both ovaries are 
absent the uterus and tubes are either altogether wanting or poorly 
developed. Menstruation and childbearing are impossible. In a 
case reported by Quain there was vicarious menstruation from the 
nose. Two of Martin's cases were sexual perverts, one a nympho- 
maniac, the other a prostitute. Martin collected twenty-two cases 
of congenital absence of one ovary. In one of his cases the uterus 
was normal, but the right tube and ovary were absent. In another 
the uterus and vagina were rudimentary, and the left tube and 
ovary absent. In nine of the twenty-two cases there was a 
uterus unicornis. The vagina and vulva are seldom influenced by 
the absence of a single ovary, and may be well-formed where both 
ovaries are absent. 

Torsion of the tube or adhesions surrounding the tube and ovary 
may shut off the blood supply and cause complete atrophy of the 
ovary. 

The diagnosis of the absence of one or both ovaries can only be 
made by inspection after the abdomen is opened. 

2. One or Both Ovaries May Be Congenitally Small. This con- 
dition may be primary or secondary. Martin reports thirty-six 
cases of rudimentary ovaries ; none menstruated, and only seven 
experienced the molimena. Twelve of the thirty-six cases had a 
rudimentary vagina, and in every case the uterus was undersized. 

Rudimentary ovaries have been recognized by a conjoined exam- 
ination, though this is exceptional. 

3. Supernumerary ovaries are accounted for either as an acquired 
segmentation of the ovary or as a congenital defect. In 500 cases 
supernumerary ovaries were found eighteen times by v. Wenkel. 
Sanger reported one that measured 1 cm. by 0.04 cm. As a rule, 



342 SPECIAL DIAGNOSIS. 

they are much smaller. Pregnancy following the removal of both 
ovaries is explained by the presence of a supernumerary ovary. 

A true supernumerary ovary is a rare finding, but an accessory 
ovary constricted off by adhesions is a comparatively frequent 
lesion. These accessory ovaries may be connected with the ovary 
by a pedicle or be completely isolated. Small pedunculated bodies 
are frequently seen near the ovaries ; these are detached tubes of 
the parovarian, small myomata of the ovarian ligament, or stalked 
corpora fibrosa. 

The clinical significance of supernumerary ovaries is in the 
continuation of the menstrual and childbearing functions after the 
removal of both ovaries. 

The diagnosis can only be made by direct inspection. 

4. One or Both Ovaries May Be Congenitally Large. This anomaly 
is occasionally found associated with precocious development of the 
sexual organs. Hypertrophy of the ovary is more often an acquired 
lesion. It is physiological during pregnancy and is commonly 
associated with uterine fibroids. It must be remembered that the 
normal ovary varies in size within wide limits. 



CHANGES IN THE POSITION OF THE OVARY. 

The normal position of the ovary is at the level of the brim of 
the pelvis midway between the horn of the uterus and the psoas 
muscle. There is a limited physiological range of motion influenced 
by changes in the position of the uterus, the filling and emptying 
of the bladder and rectum, the respiratory movements, and changes 
in the attitude of the patient. During pregnancy the ovaries are 
elevated into the abdominal cavity. 

Pathological causes of misplaced ovaries are : 

1. Displacements of the uterus and tubes. 

2. Inflammatory lesions of the ovaries, increasing the weight of 
the ovaries and causing them to fall to a lower level, or adhesions 
about the ovary drawing the organ out of place. 

3. New-growths about the ovaries, crowding them out of 
place. 

4. Increase in size and weight of the ovaries from abscesses, 
ha3matomata, and tumor formations, causing them to prolapse. 



THE DIAGNOSIS OF DISEASES OF THE OV ABIES. 343 

DESCENSUS OVARII. 

Classification (Sanger). 1. Descensus lateralis, in which the 
ovary descends no further than the upper border of the sacral liga- 
ment. 

2. Descensus posticus, in which the ovary descends below the 
upper border of the uterosacral fold. 

The causes of descensus ovarii are : 

1. Increase in the weight of the ovary by : 

a. Hypertrophy and hyperplasia. 
6. Congestion. 

c. Hsematorua or abscess. 

d. New formations. 

2. Relaxation of the supporting ligaments of the ovary. 

3. Retropositions and prolapsus uteri. 

4. Pelvic adhesions pulling upon the ovaries. 

5. Pelvic and abdominal tumors pushing the ovaries down- 
ward. 

6. Severe falls. 

In 4000 cases Martin found the ovary descended in 564, and of 
this number a single ovary was prolapsed eighty-six times. The 
greatest number was found between the ages of twenty-five and 
thirty. They are rarely seen after fifty years of age. 

A prolapsed ovary rarely remains normal. The dependent posi- 
tion interferes with the return circulation, and this leads to a 
chronic hyperplasia of the ovary (chronic ovaritis). In the 564 
cases reported by Martin chronic ovaritis was found 401 times. 
In 15 there was cystic degeneration of the ovary, and in 154 cases 
there was periovaritis with fixation from adhesions. 

The diagnosis is based altogether upon the physical findings. 
The symptoms are wholly unreliable in identifying the lesion. 
Excessive symptoms occurred only twenty-six times in the 564 
cases of Martin. Painful menstruation, dyspareunia, and pain in 
defecation are those commonly present, though they are by no 
means constant. How much parametritis and other complicating 
lesions have to do with these symptoms cannot be determined. 
Sterility does not necessarily follow. It is difficult if not impossible 
to demonstrate that the reflex symptoms, such as headache and 
dyspepsia, are dependent upon diseases of the ovary. 

The displaced ovary is recognized by its size, form, consistency, 



344 SPECIAL DIAGNOSIS. 

and sensitiveness to pressure. An anaesthetic is always of advan- 
tage and may be indispensable. A recto-abdominal examination is 
often more satisfactory than a vagino-abdominal. 

Not only must the position of the ovary be located, but it is 
necessary that the cause of the displacement be ascertained. 

HERNIA OF THE OVARY. 

Hernia of the ovary may be congenital or acquired. Congenital 
hernia of the ovary is commonly bilateral, and acquired hernia 
unilateral. Inguinal hernia is by far the most frequent form, 
though the ovary may descend through the crural ring, navel, 
ischiadic and obturator foramina. In pseudohermaphrodites the 
ovary, having descended through the inguinal canal, is likely to 
be mistaken for the testicle. Menciere reports a single case in 
which the uterus together with the ovaries and tubes were found in 
the hernial sac. So long as the ovary is not incarcerated and the 
circulation remains undisturbed no symptoms will arise. When 
from compression or torsion the return circulation is impeded the 
ovary becomes swollen from venous stasis, and may finally become 
gangrenous. The symptoms inaugurated by this condition are 
pain, vomiting, and collapse. 

The diagnosis rests exclusively upon the finding of the ovary. 
When the ovary and tube alone are found in the hernial sac and 
the abdominal wall is not thick and sensitive, there should be 
little difficulty in establishing a diagnosis. The ovary is recog- 
nized by its size, form, consistency, and sensitiveness to pressure, 
and in a conjoined examination the Fallopian tube is found to 
connect the displaced ovary with the uterus. The percussion note 
is dull in contrast to the tympanitic note of the bowel. The 
absence of the corresponding ovary in the pelvis is evidence in 
favor of hernia of the ovary. 

A hydrocele of the canal of Nuck, is distinguished from hernia 
of the ovary by the cystic, fluctuating character of the swelling 
and by the presence of the ovary in the pelvis. 

It is difficult to distinguish strangulation and gangrene of the 
ovary from a strangulated intestinal hernia. Tympany on percus- 
sion is elicited in either case. Finding the ovary in the pelvis will 
exclude the possibility of hernia of the ovary. Not infrequently 
an exploratory incision is required to establish the diagnosis. 

When the hernia is congenital or when acquired before the time 



THE DIAGNOSIS OF DISEASES OF THE OVARIES. 345 

of puberty the condition may go unrecognized until puberty, when 
the ovary becomes enlarged and tender during the menstrual periods. 

HYPERTROPHY OF THE OVARY. 

The size of the ovary varies within wide limits, and hence it is 
not always possible to distinguish between a normal ovary and one 
that is hypertrophied. 

In true hypertrophy there is an increase in the amount of 
ovarian tissue. This condition is not to be confounded with hyper- 
plasia of the connective tissue stroma, the result of passive conges- 
tion and inflammation. There are no characteristic clinical signs 
of hypertrophy of the ovary. Early puberty, unusual sexual vigor, 
and a late menopause are the ascribed manifestations. 

ATROPHY OF THE OVARY. 

The physiological atrophy of the ovary in the climacteric may 
occur some time before the menstrual periods altogether cease or 
may be delayed many years. Atrophy of the ovary usually pre- 
cedes the menopause by a year or more, but is seldom complete for 
several years after the menopause. 

A pathological atrophy of the ovary results from the interference 
with the nutrition of the organ, and from direct and continuous 
pressure upon the ovary by tumor formations and inflammatory 
exudates. Inflammatory adhesions may contract about the ovary 
and tube, limiting the blood supply and bringing on atrophy. 
Swellings of the tubes, uterus, and ovaries may cause pressure 
atrophy. Atrophy of the ovary may follow the infectious and 
contagious diseases, syphilis, diabetes, the primary and secondary 
anaemias, myxoedenia, morbus Bassedowii, tabes dorsalis, acromegaly, 
and poisoning by arsenic and phosphorus. 

Varicosities of the veins of the mesovarium have been reported 
by Palmer Dudley as being responsible for atrophy of the ovary. 
Martin, in his report of forty cases, takes the position that the 
majority of women with atrophied ovaries suffer from pulmonary 
tuberculosis. 

The menstrual functions become less active as the atrophy of the 
ovaries progresses. The individual often increases in weight. 
Nervous disturbances are frequently complained of. These are 
pain and throbbing in the head, flashes of heat and cold, insomnia, 



346 SPECIAL DIAGNOSIS. 

irritability of temper, and despondency. A positive diagnosis is 
reserved until direct inspection of the ovaries can be made. 

PARASITES AND FOREIGN BODIES OF THE OVARY. 

The echinococcus has been identified in the ovary by Freund, 
Schultze, Schatz, Orth, and Pfannenstiel. The diagnosis can only 
be made by the finding of the organism in the ovary. ^ 

Foreign bodies have rarely been found in the ovary. Calcareous 
concretions and needles have been discovered. 

CIRCULATORY DISTURBANCES IN THE OVARY. 

Etiology. There is a physiological hypersemia of the ovary 
during menstruation, coition, and pregnancy. 

The ovaries share in a general pelvic congestion, hence all embar- 
rassments to the general circulation from diseases of the heart, 
lungs, kidney, and liver, from abdominal tumors, collections of fluid 
in the abdomen, and constipation will cause passive congestion of 
the ovaries. 

In certain hemorrhagic diseases, such as scorbutus and purpura, 
there are hemorrhages into the substance of the ovaries. Hyper- 
semia of the ovary is a constant accompaniment to all the inflam- 
matory lesions in the pelvis. The more acute the lesion the greater 
the hypersemia. As remarked in the chapter on Descensus Ovarii, 
the ovary is congested. 

Hematoma of the ovary is often of obscure origin. It is possible 
for hemorrhages to occur in the ovary as the result of any of the 
above-named causes for hypersemia. As an underlying factor, we 
may have degenerative changes in the bloodvessels of the ovary. 
Such collections of blood are usually found in the follicles ; hem- 
orrhages into the interstitial spaces are less common. Yirchow and 
Olshausen each reports a case complicating scorbutus. Torsion of 
the tube and ovarian ligament may cause hemorrhages into the 
stroma and follicles of the ovary. 

Martin reported 109 cases in which blood collections in the 
ovaries varied in size from that of a bean to a man's fist. Of this 
number 25 were observed between the ages of eighteen and fifty- 
two ; 22 were not married ; the right ovary was affected forty-seven 
times, the left fifty-five times, and both ovaries thirty-two times. 



THE DIAGNOSIS OF DISEASES OF THE OVARIES. 347 

In all but 8 cases there was more or less peritonitis, and 4 of the 8 
had uterine fibroids, 1 chlorosis, 2 endometritis and metritis, and 
the eighth practised masturbation. In 26 of the 109 cases a trau- 
matic cause could be traced in the history, such as the passing of 
the uterine sound, the wearing of pessaries, and the replacing of the 
uterus. Hematoma is an unusual finding in an otherwise perfectly 
normal ovary. Any of the new formations and inflammatory lesions 
may accompany hematoma. 

Anatomical Diagnosis. In hyperemia of the ovary we find a 
slight increase in size in all diameters and a more livid color. Fol- 
lowing a long-standing hyperamiia there is an increase of the con- 
nective tissue. The tunica albuginea is thickened, and the follicles, 
failing to rupture through the thick and resisting tissue, lead to 
follicular degeneration of the ovary. 

Hematoma Ovarii. Hemorrhages into the substance of the ovary 
are found in one or more of three places — follicles, corpus luteuni, 
or connective spaces. 

1. Hemorrhages into the follicles may distend them to the size of a 
man's fist. More than a single follicle may be involved. The 
stretched walls of the follicles with their contained blood appear of 
a bluish tint. The contained blood may or may not be coagulated 
and is dark red or grayish-brown. The inner surface of the follicles 
is smooth, though occasionally made uneven by coagulated blood 
adhering to the surface. Fatty degeneration of the epithelium 
lends a yellowish tint to the inner surface. The contained blood 
may be wholly absorbed or converted into fibrin, which by contract- 
ing may obliterate the follicles. Occasionally the follicle bursts, 
and the blood escapes into the peritoneal cavity. The escaped 
blood has been known to set up a peritonitis, and cases are recorded 
where the hemorrhage was fatal. Infection of the blood may give 
rise to abscess formation in the ovary. 

2. Hemorrhages into the corpus luteiim are identified by the cor- 
rugated lining membrane of lutean cells or by a granular appear- 
ance. Such bodies are single, and are located in the periphery of 
the ovary. Hematoma of the corpus luteum has been known to 
attain the size of a child's head. 

3. Hemorrhage into the connective tissue sjmees is less common. 
Such hemorrhages are often multiple, and are seldom of large size. 
Multiple punctate hemorrhages may be distributed through the 
stroma and add materially to the size of the ovary. 



348 SPECIAL DIAGNOSIS. 

The blood is found in various stages of preservation. In fol- 
licular hematoma the epithelium lining the blood cyst may be well 
preserved, assuming a variety of shapes from cylindrical to flat- 
tened. Several layers may be found. In the larger hsematomata 
there may be but a single layer of flat epithelium, and even this 
may partially or wholly disappear through pressure atrophy. 
Blood extravasations and congested bloodvessels may be seen in 
the tunica propria. 

In the hematoma of the corpus luteum the wall is more congested 
and thicker than in the preceding variety. On the inner surface 
of the cyst there is a deposit of fibrin, in the meshes of which are 
disintegrated blood and small round cells. Beneath this are the 
lutean cells, varying in number, size, and form according to the 
age and size of the hematoma. External to the lutean cells is 
the tunica externa, composed of fibrous tissue. 

Clinical Diagnosis. There may be no clinical manifestations. 
The ovary is usually tender to pressure. Pain in the ovary may 
radiate to the back and thighs. The pain is at its height during 
the period of premenstrual congestion, and abates when a free flow 
is established. 

It has been said that when pelvic congestion is present and a 
throbbing pain develops in the ovary, with no elevation of tempera- 
ture, it is to be inferred that a hsematoma has developed in the 
ovary. A diagnosis can only be made on exploration of the ovary. 

In a bimanual examination the ovary is invariably found enlarged, 
though it is seldom larger than a walnut. The consistency is tense 
and elastic. Although sharply circumscribed, the ovary is usually 
irregular in outline. The ovary is found on a lower level than 
normal, often lying low beside or behind the uterus. 

It is difficult and often impossible to differentiate hyperemia, 
hsematoma, and inflammation of the ovary. The pain and tender- 
ness may be equally intense, and there may be no distinction in the 
physical findings. In inflammation the symptoms are usually of 
longer standing and more pronounced. The history of the onset 
should be considered. 



INFLAMMATION OF THE OVARY (Oophoritis, Ovaritis). 

For practical clinical purposes inflammation of the ovary will be 
classified as acute and chronic. 



THE DIAGNOSIS OF DISEASES OF THE OVARIES. 349 

I. Acute Ovaritis. Acute inflammation of the ovary is due to 
direct invasion of the ovary by bacteria or to the influence of their 
toxic products. Certain inorganic poisons (phosphorus, arsenic) 
act in a similar manner. 

All the infectious diseases may be complicated by ovaritis, includ- 
ing the exanthemata, typhoid fever, cholera, pneumonia, influenza, 
dysentery, wound infections, gonorrhoea, and tuberculosis. 

The micro-organisms found in the ovary under such conditions 
are the staphylococci, streptococci, pneumococci, gonococci, typhoid 
bacilli, and actinomyces. 

In all the above-named causes of ovaritis the same general ana- 
tomical changes follow, there being no essential difference in the 
anatomy of the various etiological forms. 

Pfannenstiel considers acute ovaritis under the heads : septic 
and gonorrhoeal. 

1. Acute septic ovaritis is a complication of puerperal sepsis, 
but a similar lesion may arise from the non-puerperal septic 
agencies above named. 

The ovary is uniformly enlarged and reddened, and the stroma 
becomes infiltrated with a serous exudate and small round cells. 
The follicular epithelium degenerates, the ovum dies and is absorbed, 
and the liquor folliculi becomes turbid. Suppuration may follow, 
leading to the formation of abscesses in the corpus luteum, follicles, 
and interstitial spaces. 

Death may follow, but resolution is the rule, and this is possible 
either by complete absorption of the exudate leaving the ovary in 
a normal condition, or by atrophy of the connective tissue, with its 
subsequent contraction. 

2. Acute gonorrhceal ovaritis is rarely primary, and is 
almost invariably secondary to salpingitis. In exceptional cases 
the infection is conveyed from the cervix through the lymphatics 
of the broad ligaments to the hilum of the ovary. Wertheim has 
succeeded in demonstrating the gonococcus in the ovary. 

II. Chronic ovaritis is a clinical term designating a long-standing 
lesion of the ovary characterized by hyperplasia of the stroma and 
secondary involvement of the parenchyma. 

Chronic ovaritis may be the terminal stage of an acute infection 
of the ovary. Any condition causing prolonged congestion of the 
ovary will result in chronic ovaritis, such, for example, as sexual 
excesses, menstrual congestion, subinvolution, malpositions of the 



350 SPECIAL DIAGNOSIS. 

uterus, habitual constipation, incompetency of the cardio-vascular 
system, pelvic and abdominal tumors, and disorders of the organs 
of digestion. 

Cystic Degeneration of the Ovaries. Both ovaries are commonly 
involved. They are enlarged, and the external surface is deeply 
fissured and studded with follicular swellings. They are firm in 
consistency. On cross-section of the ovary there are seen numerous 
small cystic spaces distributed throughout the thickened cortex. 
These cysts are usually not larger than an eighth of an inch in 
diameter. They may be so numerous as to almost wholly replace 
the cortical tissue and often protrude upon the surface of the ovary 
as transparent vesicles. Occasionally they are pedunculated. The 
Germans (Hegar) speak of this condition as " klein cystiche degen- 
eration." Ziegler regards the lesion as a follicular hypertrophy. 

Fig. 1G8. 




Microcystic degeneration of the ovary ; the ovary to the right shows numerous small cysts 
scattered over the surface ; these are Graafian follicles which have undergone cystic degenera- 
tion, and may take on excessive growth and develop into large tumors, or may remain as here 
represented ; on the other side is shown a similar condition of the ovary in section. (Dudley.) 

It is held by many that the hypertrophy of the follicles is of in- 
flammatory origin, the result of chronic ovaritis. Virchow called 
the lesion catarrh of the follicles. He associated it with accom- 
panying catarrh of the uterus and tubes. Klob, Popoff, and Stratz 
also contended for the inflammatory origin of cystic degeneration 
of the ovaries. 

Orth raises the question as to whether the lesion is pathological 
or an exaggerated physiological process. Nagel denies their path- 
ological significance and regards them as purely physiological. 
They are repeatedly seen in the ovaries of infants and even before 
the period of viability. 



THE DIAGNOSIS OF DISEASES OF THE OVARIES. 351 

The tunica albuginea is thickened save where it is thinned by 
pressure of the underlying cysts. The covering germinal epithelium 
is intact. The connective tissue stroma of the ovary is greatly 
increased in amount, unless the number and size of the follicles 
replace the stroma. There is little or no round-cell infiltration 
except during periods of acute ] exacerbation. The arteries are 
thick-walled, and may undergo hyaline degeneration. From the 
bloodvessels of the tunica interna a serous exudate fills the follicles, 
giving rise to what is known as hydrops folliculi. In the distended 
follicle the lining membrane becomes compressed and the ovum is 
absorbed. 

Abscess of the Ovary. We may speak of acute and chronic 
abscesses of the ovary. 

1. Acute abscess of the ovary is seldom recognized in a clinical 
examination. Such abscesses commonly arise in the course of acute 
general septic infections with a speedy fatal termination. Hence 
it is the rule that acute abscesses of the ovary are usually discovered 
in a postmortem examination. 

2. Chronic Abscess of the Ovary. Menge, in 33 cases of 
ovarian abscesses, found the gonococcus in 9, the colon bacillus in 4, 
the streptococcus in 1, saprophitic anaerobic micro-organisms in 1, 
and in 1 8 the pus was found sterile. Martin found the pus sterile 
in 20 out of 55 cases. 

Anatomical Diagnosis. As in haBinatorna, so in abscess of the 
ovary, there are three localities in which they may develop — the 
interstitial spaces, the follicles, and the corpus luteum. 

Interstitial abscesses are found in all portions of the ovary. They 
are usually multiple and irregular in outline. The wall of the abscess 
is composed of connective tissue infiltrated with small round cells. 

Follicular abscesses usually present a smooth wall of connective 
tissue. They may be single or multiple, and may attain the size of 
a man's head. 

A corpus luteum abscess is recognized -by the corrugated inner 
lining of the cyst wall. The abscess lies superficially and is usuallv 
single. The blood coagulum in the centre of a corpus luteum is a 
favorable nidus for pyogenic micro-organisms. This, with the 
superficial position of the corpus luteum and its intimate connection 
with an infected tube, makes infection easily possible. 

Tubo-ovarian abscess, by which is understood a pyosalpinx directly 
communicating with an ovarian abscess, may be primary or sec- 



352 SPECIAL DIAGNOSIS. 

ondary. A primary tubo-ovarian abscess begins as a pyosalpinx 
and an ovarian abscess, which later communicate and form one 
continuous abscess cavity. A secondary tubo-ovarian abscess arises 
from a secondary infection of a primary tubo-ovarian cyst. 

In 110 cases of ovarian abscesses Martin found a tubo-ovarian 
abscess in 18. 

Clinical Diagnosis of Ovaritis. The clinical picture is a 
variable one. The ovary is seldom involved alone, hence the 
clinical picture of ovaritis is seldom observed independently of 
complicating inflammatory lesions. 

Acute ovaritis causes a rise of temperature and increase in the 
pulse rate. There is exquisite tenderness on pressure over the 
ovary — so much so, that an anaesthetic is required in palpating the 
ovary. For practical purposes a diagnosis of acute inflammation 
of the adnexa is sufficient. When the acute stage of the inflamma- 
tion has subsided the ovary can be outlined. 

In chronic ovaritis there is no elevation in temperature. Pain in 
the region of the affected ovary radiating to the groin and thigh is 
the most constant symptom. Occasionally the pain recurs at 
regular intervals between the menstrual periods (" muttleschmertz"). 
The explanation of this phenomenon is the ripening and bursting 
of the follicles through the resisting stroma and tunica albuginea. 
Individuals show a marked difference in their susceptibility to 
pain. Chronic ovaritis may exist to a marked degree without 
causing pain, while on the other hand, a very slight involvement 
of the ovary may cause intense suffering. The pain is aggravated 
during the period of premenstrual and menstrual congestion. The 
pain of chronic ovaritis is often but the expression of a general 
nerve storm, and it is difficult, indeed, to determine just how much 
the lesion in the ovary has to do with the pain. 

In the early stage of chronic ovaritis the menses are increased, 
but, as the true ovarian tissue gives place to connective tissue, the 
menses become more and more scanty. Sterility is a common com- 
plaint, and is the immediate result of such complicating lesions as 
salpingitis and endometritis more often than of ovaritis. When 
the cause of sterility rests in the ovary, the explanation lies in the 
destruction of the ova and in the failure of the follicles to rupture 
through the thickened stroma, tunica albuginea, and surrounding 
adhesions. 

When suppuration of an ovary follows upon ovaritis the symp- 



THE DIAGNOSIS OF DISEASES OF THE OVARIES. 353 

toms are all aggravated. In acute abscess of the ovary the symp- 
toms are all marked by the complicating peritonitis, metritis, and 
salpingitis. 

Increase in the pulse rate and elevation of temperature are to be 
expected in acute abscesses, but are often wanting in the chronic stage. 

In determining the cause of the infection it is important to 
consider the clinical history, as a possible childbirth, abortion, or 
gonorrhoea! infection may play a part. Physical examination of the 
pelvic viscera and of the leucorrhoeal discharge may reveal a gonor- 
rheal or tuberculous infection of other portions of the genital tract. 

The diagnosis is made in part by a consideration of the above 
symptoms, but an absolute diagnosis cannot be made without a 
physical examination, and is often reserved until an exploratory 
incision offers further light. 

Tenderness and pain may be complained of in the presence of a 
perfectly normal ovary, and chronic ovaritis may exist without 
causing pain or tenderness on pressure. 

Direct palpation of the ovary in a bimanual examination under 
anaesthesia is indispensable in making a diagnosis. The slight 
increase in size and consistency of the diseased ovary, together with 
evidence of infection elsewhere in the genital tract, will best suggest 
the diagnosis. 

The diagnosis cannot be based upon the increase in size in the 
absence of pain and tenderness. Hypertrophy and cystic degen- 
eration of the ovary will cause a similar increase in the size. 

Abscess of the ovary cannot be diagnosed from constitutional 
symptoms. Chills, fever, rapid pulse, and pain may all be absent 
in the presence of an ovarian abscess. 

The diagnosis is based upon the finding of a rounded swelling 
beside or behind the uterus, and not immediately connected with it. 
The tube may be traced from the swelling to the horn of the uterus. 
The ovary is tender to pressure, and is always restricted in its 
movements by adhesions. Fluctuation is not often elicited. 

It is sometimes possible to judge of the liability of the abscess to 
rupture by the degree of tension associated with the pain. At 
such a time the temperature and pulse are usually elevated, and 
there are increasing pressure symptoms referred to the rectum 
and bladder, and along the sacral nerves to the thighs and back. 

On rupture of the abscess the temperature may drop and the 
pain cease. If the abscess has ruptured through the vagina, rec- 

23 



354 SPECIAL DIAGNOSIS. 

turn, bladder, or abdominal wall there will be an escape of pus, 
which is usually fetid and mixed with blood. If the abscess rup- 
tures into the peritoneal cavity and the pus is confined by adhesions, 
there will be a moderation in the temperature and pain. If no 
adhesions protect the peritoneum there will rapidly follow symp- 
toms of general suppurative peritonitis. Return of the abscess 
in the ovary is of common occurrence. Fistulse and chronic sup- 
puration are possible results which demand the removal of the sac 
long after a spontaneous rupture. 

Differential Diagnosis. Congestion of the ovary may be mis- 
taken for an inflammation. The history of the development of the 
lesion and the duration and intensity of the disturbance are the 
guides to a diagnosis. No sharp line can be drawn between these 
lesions even by anatomical studies of removed ovaries, and hence 
it is impossible to clearly define the two conditions. 

Salpingitis is often associated with ovaritis, and the two may be 
inseparably connected, so that it is impossible to distinguish the 
ovary from the tube in a bimanual examination. Adhesions bind- 
ing the tube and ovary may unite them into a single rounded or 
oblong tumor mass. 

In general it may be said that inflammatory swellings of the 
tube are elongated, retort-shaped, and immediately connected with 
the horn of the uterus, while inflammatory swellings of the ovary 
are round and not so intimately connected with the uterus. 

Parametric exudates lie at a lower level in the pelvis than does 
an ovarian abscess. The swelling is more diffuse and is absolutely 
immovable. Furthermore, a parametric exudate is intimately 
connected with the uterus, and is more often unilateral than are 
ovarian abscesses. An ovarian abscess is slower in its development 
and slower in being absorbed than is a parametric exudate. 

Perityphlitis is usually not difficult to distinguish from inflamma- 
tory lesions of the ovary. The higher location on the right side and 
the accompanying disturbances of the digestive organs will usually 
serve to exclude the ovary. The diagnosis will be made with 
certainty by outlining the ovary apart from the perityphlitic 
exudate. 

New-growths of the ovary, including ovarian cysts, are less tender 
to pressure, the pain is rarely so fixed, and the outline of the tumor 
is often quite irregular. Finally, their tendency to grow to a large 
size will serve as points of distinction. 



THE DIAGNOSIS OF DISEASES OF THE OVARIES. 355 

SIMPLE CYSTS OF THE OVARY. 

Among simple cysts of the ovary will be included those cystic 
formations occupying an intermediate position between the cystic 
inflammatory lesions and the cystic new formations. 

1. Follicular Cysts. See Chronic Ovaritis. 

2. Corpus luteum cysts, as the name implies, arise from the corpus 
luteum, and hence are single and are located on the periphery of the 
ovary. As compared with follicular cysts, they are thick-walled. 
In size they vary from a bean to a man's head. 

The wall of the cyst presents the characteristic yellow corrugated 
appearance of the luteum cell layer, and external to this is the pale, 
fibrous envelope. The contents of the cyst is commonly a clear, 
serous fluid ; this is occasionally mixed with blood and degenerated 
cells. 

3. Tubo-ovarian Cysts. These have been previously referred to. 
Rathorn gives the following groups in explanation of the origin 

of tubo-ovarian cysts : 
Group I. 

1. Cases in which a pyosalpinx becomes adherent to the wall 
of an ovarian abscess, with subsequent communication established 
between them. Later the formed elements of the pus are absorbed, 
leaving a serous fluid. 

2. Adhesions of the pavilion of the tube to the wall of the sup- 
porting ovarian cyst, with subsequent development of hydrosalpinx 
and perforation of the cyst into the tube. 

3. Adhesions of a hydrosalpinx to a papillomatous cyst, with 
subsequent perforation of the intervening wall by papillary growths. 

Group II. 

1. Cases in which a hydrosalpinx becomes adherent to the wall 
of a follicular cyst, with subsequent perforation of the septum. 

2. Cases in which the fimbria? of a previously diseased tube 
become caught in the opening of a ruptured follicle at the moment 
of rupture and become adherent to the wall of the follicle. 

Anatomical Diagnosis. A tubo-ovarian cyst may distend to 
the size of a child's head. The general form is that of a retort. 
The wall is thin and transparent. Occasionally there are adhesions 
about the cyst. ~No evident ovarian tissue may be found. 

The interior of the cyst resembles a hydrosalpinx on one side and 
a follicular or corpus luteum cyst on the other. There is but a 



356 SPECIAL DIAGNOSIS. 

single cavity. The point of union of the cyst and tube is sharply 
defined. The tubal portion is lined with ciliated epithelium and 
the ovarian portion either with a fibrous or granular surface layer or 
with a low type of epithelium. The contents is clear serum, rarely 
blood-stained. 

The clinical diagnosis cannot be made from hydrosalpinx. ' The 
diagnosis is only made by a careful examination of the specimen 
after its removal. 



INFECTIOUS GRANULOMATA OF THE OVARY. 

Of the infectious granulomata we find in the ovary tuberculosis, 
syphilis, actinomycosis, and leprosy. 



Tuberculosis. 

Etiology. Tuberculosis of the ovary is a comparatively rare 
lesion. One hundred and eighty-four cases were reported by 
von Guillemain, Wolf, Martin, and Bulius. In Wolfs cases 42 were 
bilateral, 48 unilateral. No case of primary tuberculosis of the 
ovary has been reported. However, the ovary may be the primary 
seat of attack in the genital organs when the initial lesion lies else- 
where in the body ; but this is rare. As a rule, the primary lesions 
lie within the tube or in the peritoneal cavity. In 410 cases of 
tuberculosis of the genital tract the ovary was involved in 84. 
Bland Sutton says : " An ovarian abscess unassociated with salpin- 
gitis is in nearly all cases tuberculous. Records of ovarian tuber- 
culosis require careful and critical consideration before acceptance. " 
The invasion of the ovary is usually by direct continuity from the 
peritoneum and tubes to the ovary ; more rarely by the lymph and 
blood streams. 

Anatomical Diagnosis. Martin classifies the tuberculous lesions 
of the ovary as follows : 

1. Tuberculous periovaritis, in which the tubercles are distributed 
over part or all of the surface of the ovary as miliary or larger 
tubercles. It is a direct invasion of the ovary from the tube and 
peritoneum. 

2. Tuberculous ovaritis, in which miliary tubercles are distributed 
throughout the ovarian tissue. More often distinct cheesy masses, 
or tuberculous abscesses, are found to occupy the interior of the 



THE DIAGNOSIS OF DISEASES OF THE OVARIES. 357 

ovary. Cheesy masses rarely reach the size of a hazelnut, while 
tuberculous abscesses may attain the size of a child's head. 

Tuberculous tubo-ovarian abscesses have been reported by 
Williams, Menge, and Mosler. The author adds another case. As 
a rule, the lesion is bilateral ; occasionally ascites accompanies tuber- 
culosis of the ovary, and is the result of tuberculous peritonitis. 

Microscopic Diagnosis. In tuberculous periovaritis there are 
typical tubercles on the surface and in the neighborhood of the 
ovary. The surface epithelium is intact, save where the tubercles 
are located. The superficial tubercles may directly invade the 
underlying stroma. This is accomplished by way of the lymph or 
blood stream. In a case of Frank the lutean cell layer was covered 
with miliary tubercles. No primary invasion of the follicles has 
been observed. The usual point of invasion is the connective tissue 
stroma. Cheesy masses are generally sharply defined from the sur- 
rounding stroma and are single or multiple. Tuberculous abscesses 
of the ovary are usually lined with irregular cheesy walls and granu- 
lation tissue beset with miliary tubercles. The surrounding con- 
nective tissue contains giant cells and tubercles, and commonly 
undergoes hyaline degeneration. The tubercles may be found in 
the purulent contents of the abscess or in the abscess wall. Sec- 
ondary infection with pyogenic organisms have been demonstrated. 
Dermoid cysts have been known to contain tubercle bacilli. 

Clinical Diagnosis. Since primary tuberculosis of the ovary 
has not been recognized, it has not been possible to say just what 
the symptom-complex would be. We find the usual general and 
local evidences of chronic ovaritis. The tuberculous character is 
inferred from the family and personal history, and the finding of 
tuberculous lesions elsewhere in the body, particularly in the tubes 
and peritoneum. 

SYPHILIS OF THE OVARY. 

Syphilitic lesions are rarely found in the ovary. Orth reported 
the finding of a gumma. Bichet also describes hyperplastic and 
atrophic changes in the ovary due to syphilis. Lecorche" found in 
a postmortem case hyperplastic changes in the ovaries with cal- 
careous nodules in the cortex. In this case death was caused by 
general syphilitic infection. Tuberculosis and syphilis have been 
observed to coexist in the ovary (Baumgarten). 



358 SPECIAL DIAGNOSIS. 

The diagnosis cannot be determined because of the lack of oppor- 
tunities for observation. In syphilitic infection with accompanying 
lesions of the ovary, if the regular antisyphilitic treatment results 
in a cure of the ovarian lesion, the diagnosis is established. 

ACTINOMYCOSIS OF THE OVARY. 

This is a very rare condition, and is a secondary invasion from 
the vagina or intestine. Abscesses, single or multiple, are found 
in the ovary. They are usually interstitial. There is nothing to 
characterize their true nature from other abscesses save in rinding 
the organism in the pus. The diagnosis cannot be made without a 
microscopic examination of the purulent contents. 

LEPROSY OF THE OVARY. 

Babes found inflammatory lesions in the ovary together with the 
specific organism which he ascribes to leprosy. The presence of 
leprosy elsewhere in the body with a chronic ovaritis of no assign- 
able origin affords a probable diagnosis. 

NEW FORMATIONS OF THE OVARIES. 

Etiology. Ovarian tumors were found in 1.4 per cent, of 36,158 
cases in Martin's clinic. The following table from Stander shows 
the relative frequency of various tumors of the ovaries : 

Cystadenoma 205 = 69. 49 percent. 

Carcinoma 40 = 13.56 " 

Embryoma 26 = 8 81 " 

Sarcoma . . 20 = 6.78 

Fibroma . . 4 = 1.36 

Referring to the age at which ovarian tumors appear, we find 
Doran reporting a case of sarcoma of the ovary in infancy, and 
Homans operating upon a tumor of the ovary at eighty-two years 
of age. The following is a table prepared by Olshausen in which 
are given the number of tumors found and the respective ages of 
the patients : 

61 under 10 years. 

490 between 20 and 29 " 

499 . 30 " 39 " 

372 " 40 " 49 " 

342 at 50 " over. 



THE DIAGNOSIS OF DISEASES OF THE OVARIES. 359 

It will be seen from the above table that tumors of the ovary 
occur with about equal frequency between the ages of twenty and 
fifty years. 

The social state has no influence upon the development of ovarian 
tumors ; they occur with about equal frequency in the single and 
married. They may be the cause of sterility, but it is not likely 
that sterility predisposes to their development. 

While two or more members of the same family have been known 
to be afflicted with ovarian tumors, it is not believed that heredity 
plays a role in the development of these neoplasms. In 1000 cases 
of Spencer's, 8.2 per cent, were bilateral, while Olshausen gives 
13.7 per cent, in 322 cases. 

Classification. The old classification of tumors of the ovary 
into cystic and solid tumors was of the greatest service when the 
operative treatment was limited to the tapping of fluid. At the 
present time, when tumors of the ovary are removed en masse, such 
a classification does not meet the requirements. 

Tumors of the ovary are classified as benign and malignant. 
Waldeyer classifies them according to their histology and histogenesis, 
into epithelial (parenchymatous) and connective tissue (interstitial) 
forms. Either of these forms is benign or malignant, and may be 
cystic or solid. A combination of the parenchymatous and inter- 
stitial forms are the so-called mixed tumors. 

Epithelial new formations of the ovary take their origin from 
the germinal epithelium of the follicles, rarely from Miiller's duct. 
From these sources are derived the benign and malignant, the 
cystic and the papillary tumors. 

An adenoma, pure and simple, is rarely seen. More often it is a 
combination of adenoma and fibroma (adenofibroma). When the 
gland spaces widen we speak of cystadenoma. These large cystic 
spaces result from the distention of glands by the retained secretions 
(non-proliferating cysts), and from proliferation of the epithelial 
and connective tissue elements in addition to the distention of the 
glands. 

The secretion of these cysts differs. Pfannenstiel introduced the 
terms cystadenoma jiseudomucosum when the contents is of a mucous 
character, and cystadenoma serosum when the contents is serous fluid. 

The purely glandular type may be found, or papilla? may spring 
from the surface of the cyst. It is possible to have a papillary cyst 
on one side and a glandular cyst on the other. One may be intra- 



360 SPECIAL DIAGNOSIS. 

peritoneal, the other extraperitoneal. They are rarely of equal size. 
Intraperitoneal cysts are pedunculated and are usually freely mov- 
able, while extraperitoneal cysts seldom have a pedicle and are 
fixed. Such extraperitoneal cysts are usually completely enfolded 
in the broad ligament, but are sometimes partly within the free 
peritoneal cavity. Cysts of very large dimensions may have but a 
single cavity, but, as a rule, one or more smaller cysts lie within 
the parent cyst and are known as daughter cysts. These smaller 
ones give an irregular surface and a variable consistency to the 
original cyst. By rupture of the daughter cysts into the parent 
cyst a multilocular may be converted into a unilocular cyst. There 
are usually some remnants of the walls of the daughter cysts left 
in the form of ridges and bands. 

As the cyst enlarges the wall becomes thinner, more transparent, 
and glistening. In the wall of the cyst many bloodvessels are seen 
to take an irregular course ; the veins are larger and more numer- 
ous than the arteries. 

Villous projections are frequently seen growing from the inner 
surface of the cyst wall. The villosities vary in size and extent 
and form wart-like excrescences, sometimes long and slender, like 
a feather. The framework of the papillae is of connective tissue in 
which bloodvessels course. Covering the stroma are one or more 
layers of columnar epithelium, showing many irregular foldings and 
reduplications which might be mistaken for malignant proliferation. 
The connective tissue growth does not keep pace with that of the 
epithelium. Similar papillary growths appear on the external sur- 
face of the cyst. These arise either from the surface epithelium or 
from within the cyst and subsequently penetrate the wall. 

Microscopic examination of the cyst wall shows a vascular frame- 
work of connective tissue with more or less round-cell infiltration. 
In the smaller cysts true ovarian tissue is sometimes present. On 
the outer surface of the cyst wall germinal epithelium is commonly 
seen, though it may be partially or wholly lost. The inner surface 
is lined with a secreting epithelium of cylindrical form and often 
ciliated. This epithelium remains intact, whatever the size and 
age of the cyst. To the unaided eye the inner surface appears not 
unlike the mucous membrane of the stomach. 

When nutrition is insufficient certain retrogressive changes fol- 
low. Occasionally the cyst contents are absorbed, and the cyst 
wall contracts, thereby diminishing its size. 



THE DIAGNOSIS OF DISEASES OF THE OV ABIES. 361 

Calcareous degeneration of the cyst wall may be partial, or, as in 
the case of Leopold, complete. 

Other secondary changes in the cyst, to be described later, are 
hemorrhage into the cyst, torsion of the pedicle, rupture of the wall, 
infection of the contents, and malignant degeneration. 

Rupture of a cyst may be followed by closure of the rent and 
refilling of the cyst, or the rent may remain open and the contents 
be discharged continuously into the peritoneal cavity. In excep- 
tional cases the cyst shrinks and disappears after rupture. 



Fig. 169. 




Multilocular ovarian cyst, sometimes called ovarian adenoma, in section ; the larger cavity is 
primary; the smaller cavities, secondary. (Dudley.) 

If the contents of the cyst are serous the escaped fluid will be 
absorbed, but if mucus escapes into the peritoneal cavity absorption 
is slow and a pseudomyxomatous peritonitis may possibly develop. 
Small hemorrhages into the cyst wall are of common occurrence, 
and have no clinical significance. Hemorrhagic effusions into the 
cyst wall predispose to rupture, and life may be endangered by the 
rupture of large bloodvessels. 

When torsion of the pedicle shuts off the blood supply and there 
are no adhesions through which nourishment is carried to the cyst, 



362 



SPECIAL DIAGNOSIS. 



atrophy or gangrene of the cyst will follow. It is possible for 
adhesions to convey sufficient blood to fully nourish the cyst and 
even permit it to increase in size. 

a. Cystadenoma pseudomucinosum (Hammarstan) contains a 
mucinous secretion, clear and transparent, or turbid from cell debris 
and blood. A large amount of blood may give a chocolate color to 
the fluid. White, flocculent particles float in the fluid. These 



Fig. 170. 




Multilocular ovarian cysts, sometimes called ovarian adenoma. (Dudley.) 



consist of mucin, cell debris, cholesterin, blood corpuscles, and fat 
droplets. The epithelium lining the cyst is a single layer of high, 
slender, cylindrical cells, with clear, transparent bodies, and oval 
nuclei near the base. 

The pseudomucinous cysts are by far the most common of the 
large ovarian cysts. They are commonly adenomatous, rarely 
papillomatous, though a limited number of papillary growths is 
often found projecting from the cyst wall. 



PLATE XL. 



v\a /I 














^' 


/fj n ^ 




"i v 






<? 




i'v. 








v^i 






^ 


\ w 












4 ^i'' #*£ 




















#1 










k 
^v,^ 






mm£* 










'-^..j**' f~ f 1 





'apilloma of the ovary. 



THE DIAGNOSIS OF DISEASES OF THE OVARIES. 363 

Fig. 171. 



* 










% 










<& 










, 










V 










'V 










'■■- «> 












t* &**"■ 


















ft *"-■ 






-^««t' a »,. 


-«*»v«*«k£**^\..-; ; 


>i m - 










43 










S A 






























' a 




















.*.-- 










■ '- i ** 










4% 










• 
























i > • 






j^ 


' . ' 


- ' s « . 







Pseudomucinous ovariau cyst. The cyst is lined within by a single layer of nigh columnar 
epithelium with an oval nucleus near the base of the cell. The cyst wall is composed of con- 
nective tissue containing gland-like structures. 

Fig. 172. 




Papillomatous ovarian disease On the right side is a cyst irom the paroophoron or vascular 
zone of the ovary ; in the wall of this cyst have developed three secondary cysts, which are 
shown in section and which contain warty growths ; observe also the warty growths both on 
the outside and inside of the cyst ; to the left is a superficial papilloma of the ovary, which 
lies between the ovary and the uterus. Papillomatous disease on the inside of this ovary is 
also shown in section. (Dudley.) 



364 SPECIAL DIAGNOSIS. 

According to Martin, more than two-thirds are unilateral ; only 
about 7 per cent, are extraperitoneal. The largest recorded cyst 
weighed 245 pounds. 

b. Oystadenoma serosum contains a clear serous fluid of a pale 
green color ; it is rarely turbid from admixture with cell debris, or 
chocolate color from admixture with blood. 

These cysts rarely attain the enormous size of the mucinous 
variety. They are frequently papillary, and as such are often 
bilateral. 

Papillary growths may not only cover the inner surface of the 
cyst and penetrate to the outer, but may spread by continuity of 
tissue to the peritoneum, where by mechanical irritation ascitic 
fluid is secreted. 

A papillomatous growth of the ovary without cystic formation is 
an unusual condition. The secreting epithelium consists of low r 
cylindrical-shaped cells, with round nuclei near the centres. 

CARCINOMA OF THE OVARY. 

Our knowledge of primary carcinoma of the ovary is very 
limited. The majority of carcinomata are secondary. 

Classification. Waldeyer gives the following classification : 

1. Simple (carcinoma simplex). 

2. Medullary (carcinoma medullaris). 

3. Scirrhus (carcinoma schirrosum). 

Many secondary forms may be added, such as atrophic, colloid,, 
melanotic, sarcomatous, gelatinous, and microcystic. 

The frequency of carcinoma of the ovary is stated by Martin as 
13.6 per cent, of his cases of ovarian tumors. 

About three-fourths of them are unilateral. Bilateral invasion 
of the ovary is always associated with involvement of the peri- 
toneum and other structures, and hence is inoperable. 

As pointed out by Sutton, it is a curious rule that organs which 
are frequently the seat of primary carcinoma are rarely the seat 
of secondary deposits, and vice versa. This is exemplified in the 
ovary. In primary carcinoma of the mammary gland the ovaries 
were invaded five times in 85 cases (Coupland.) Sutton found the 
ovaries invaded six times in 52 cases of inoperable carcinoma of 
the uterus, and three times in 29 cases of inoperable carcinoma of 
the breasts. 



PLATE XL! 




Cystic carcinoma of the ovary, with extension to the 
intestinal and parietal peritoneum and to the omentum. 
( Dudley. ) 



THE DIAGNOSIS OF DISEASES OF THE OVARIES. 365 

Olshausen says an important feature in the clinical history of 
ovarian cancer is the fact that it often occurs at an early age and 
may even develop during childhood. The following table was con- 
structed by Olshausen : 

8 to 19 years 10 patients. 

20 " 29 " 17 

30 " 39 " 8 

40 " 49 " 15 

50 years and above 17 " 

Anatomical Diagnosis. In solid carcinomatous tumors of the 
ovary the general form of the ovary is maintained. The surface is 
uneven and studded with tubercles, nodules, or papillary groAvths. 
Rarely is the surface smooth. It is unusual to find normal ovarian 
tissue, yet the occurrence of pregnancy in bilateral involvement of 
the ovaries shows that some follicles remain healthy. In the large 
tumors cystic spaces are invariably present. Malignant degenera- 
tion of ovarian cysts is of more common occurrence. In all forms 
of carcinoma of the ovary the carcinoma cells maintain their cylin- 
drical shape and form cancer nests or gland-like structures not 
dissimilar to those found in carcinoma of the Fallopian tube. 

Papillary growths which have perforated a cyst wall are prone to 
undergo malignant degeneration and to rapidly spread to the peri- 
toneum. As pointed out by Abel, where cancerous degeneration is 
suspected, the cyst should not be tapped before removal for fear of 
contaminating the peritoneum and setting up metastatic growths. 

Squamous-cell carcinoma of the ovary has been observed in der- 
moid cysts. 

Metastasis does not occur so widely in carcinoma of the ovary as 
in carcinoma of the uterus. The most likely points of invasion are 
the peritoneum, omentum, and retroperitoneal glands. 

DERMOID CYSTS OF THE OVARY. 

Dermoid cysts, as the name suggests, are cystic tumors containing 
skin structures. 

In Martin's classification we find simple dermoid cysts, com- 
plicated dermoid cysts, teratoma, and solid teratoma. 

A simple dermoid cyst is a sac lined with a dermal membrane. 
A complicated dermoid cyst is lined with skin and contains hetero- 
geneous structures, such as glands, bone, and teeth. A teratoma 
contains formed organs, such as brain, mammary glands, thyroid 



366 SPECIAL DIAGNOSIS. 

glands, etc. A solid teratoma contains no large cysts and is com- 
posed of structures similar to those found in ordinary teratoma. 

From Bandler we quote : " The pronephros, the Wolffian body, 
and the Wolffian duct, through their position in the mesoderm, 
their connection between ectoderm and coelome, their relation to the 
normal development of the ovary, their subsequent position at the 
hilus of the ovary and the extension of the tubules into the vas- 
cular layer and their growth through the ovary even up to the 
surface, and from the fact that their remnants furnish the ciliated 
growths of the broad ligament and form the cystadenomata of the 
ovary, are capable of carrying with them mesodermal and ecto- 
dermal cells up to or into the ovary, and of forming mesodermal 
and ectodermal products and structures lined with ciliated epithe- 
lium Cysts of the testicles lined with ciliated 

epithelium originate from remnants of the Wolffian body tubules. 
Therefore, the mesodermal tumors, the mixed tumors, and the 
dermata of the ovary and testicles originate in this same manner. 

If ectodermal cells are displaced to any extent 

so that their presence is manifested by cutis-like tissue, hair, seba- 
ceous glands, etc., we speak of dermoid cysts. If the displaced 
cells are, so to speak, located in one part of the organ concerned, 
and if they grow equally, and if the skin cells, as in the normal 
skin and the sebaceous glands, excrete their products, a cystic der- 
moid must result. Since the contents found in dermoid cysts are 
excreted by the so-called ' derm , of the cyst, they must lie, when 
secreted, between the derm and the enveloping tissue composing 
the organ or tissue in which the dermoids grow. The larger the 
amount of this secretion the greater is the pressure on the secondary 
tissue. If the mass of the secreted matter reaches a fair amount, 
and if it causes a tissue growth in its periphery, and if it compresses 
the overlapping organ so that it is stretched or flattened, we then 
have a cystic dermoid whose wall consists of so-called ' skin,' of 
granulation tissue, and of the tissue of the enveloping organ. The 
original group of displaced cells is found then as a prominence only 
in one part of the so-called cyst wall, and it is this part which grows 
gradually for years, and in which are found the hair, the sebaceous 
glands, and other elements found in the inner surface of a dermoid 
cyst. The greater the amount of substance secreted, and the greater 
the amount and number of the products found by the displaced 
ectodermal and mesodermal cells, the larger the cyst. 



THE DIAGNOSIS OF DISEASES OF THE OVARIES. 



367 



" If, on the other hand, the displaced cells are not grouped in 
one part of the organ concerned, and if, at the same time, the ecto- 
dermal cells are not present in too great number, there develops a 
tumor in which the various tissue forms grow into each other. Since 
these ectodermal cells do not form in such a case a so-called ' derm/ 
and since they cannot bring about the formation of a cyst through 
their excretion as above described, a tumor form results which is 
relatively solid and which seems to be of an entirely different 
structure — a so-called ' teratoma.' 



Fig. 173. 




Dermoid ovarian cyst in section, showing inside of cyst cavity, which contains a lower jaw 
and a fragment of another jaw r , with teeth, small fragments of bone, and considerable bair ; 
the upper mass of hair is in tbe shape of a ball, and is held together by the fatty contents of 
the cyst, which, at the temperature of the body, is liquid, but becomes solid upon exposure to 
the ordinary temperature of the air— that is, about 70° F. (Dudley.) 



" In ovarian dermoids and teratomata ectoderm is present in 
large amount ; therefore, teeth are frequently found, and their 
occurrence is in contrast with their rarity in the testicle. The 
origin of teeth is to be explained by the united presence of ectoderm 
and mesoderm in these tumors." 



368 



SPECIAL DIAGNOSIS. 



Anatomical Diagnosis. A dermoid cyst may occupy part or 
all of the ovary, and as many as five distinct and separate dermoids 
have been found in the same ovary. They are commonly intra- 
peritoneal and are rarely found between the layers of the broad 
ligament. Both skin and mucous membrane are found in the cysts. 
The amount of skin found varies greatly. It may completely line 
a large cyst or may be confined to a single daughter cyst. 

Fig. 174. 




A composite drawing of the microscopic appearance of a dermoid, a, an epithelial pearl 
in section ; b, glandular tissue ; c, developing hairs ; d, developing teeth ; e, sweat gland in 
section. 



Cutaneous appendages found in the skin of the dermoid are hair, 
teeth, nails, horns, sebaceous and sudoriferous glands, mammae, 
bone, unstriped muscle fibre, brain and nerve tissue. 

The hair may be rolled into a ball and lie free in the cyst cavity, 
or tufts of hair may spring from the cyst wall. The hair has been 



THE DIAGNOSIS OF DISEASES OF THE OVARIES. 369 

known (Munde) to be five feet in length. The color varies from 
blond to black, and does not usually correspond to the color of the 
patient's hair. It is known to turn gray in old age, and at this 
time the cyst may become bald. 

The teeth may be embedded in bone resembling a rudimentary 
jaw or in the fibrous wall of the cyst. More than 400 teeth have 
been found in a single dermoid cyst of the ovary. They represent 
teeth of every description and develop on the same plan as teeth in 
the normal situation. They are not scattered irregularly through 
the cyst unless present in large numbers, but are grouped together. 

Xails and horns project from the surface of the cyst. Sebaceous 
and sweat glands may be numerous, and may form retention cysts. 
Bone in shapeless masses or in plates is occasionally found. Xerve 
matter has been detected in dermoid cysts. 

Mammae, in the form of a nipple attached to rounded projections 
of tissue containing sebaceous glands and more or less fat, are occa- 
sionally found, and completely formed glandular structures have 
been discovered. Dr. Desiderius reported a case in which the 
gland secreted milk and colostrum. 

Dermoid cysts of the ovary occur at any period of life, from birth 
to eighty years of age, and are to be regarded as the most common 
abdominal tumor in girls and young women. The rate of growth 
varies from a few months to many years in attaining the maxi- 
mum size. They are rarely larger than the patient's head, and 
may be self-limiting in their growth. As a rule, adhesions bind 
the cyst to the intestine. Suppuration and malignant degeneration 
are the peculiar characteristics of dermoid cysts of the ovary. 

CONNECTIVE TISSUE NEW FORMATIONS OF THE OVARY. 

Fibroma, myoma, myxoma, enchondroma, osteoma, angioma, 
lymphangioma. 

Fibroma of the Ovary. 

Of the connective tissue tumors of the ovary, fibroma is the most 
frequent. They are found with about equal frequency between the 
ages of twenty and fifty, and have been met with as early as ten 
or as late as eighty years of age. 

Orthmann classifies fibroids of the ovary as superficial and diffuse. 

24 



370 SPECIAL DIAGNOSIS. 

a. Superficial fibroids are commonly small, rarely larger than a 
walnut. They are single or multiple, and sessile or pedunculated 
in their attachment to the tunica albuginea. Their consistency is 
firm, and the external surface is smooth or furrowed. On cross- 
section whorls and bands of fibres are seen. Germinal epithelium 
covers the surface of the tumor. 

b. Diffuse fibroids have rarely grown larger than a man's head. 
Clemens reported one weighing 40 kilos. The contour varies from 
round and smooth to irregular and nodular. The amount of blood 
supply is variable, and hence the color of the tumor varies from a 
pale gray to a yellowish-red. Unless there are degenerative changes 
their consistency is uniformly firm. 

Adenofibroma of the ovary is an occasional finding and consists of 
glandular tissue in a fibrous framework. 

Myoma of the Ovary. 

The origin of myoma of the ovary is probably the muscle fibres 
of the vessel walls and the ovarian ligament. They are rare. None 
larger than a man's fist has been reported. In general appearance 
they closely resemble fibroids. 

Myxoma ovarii appears as a degenerative form of an ovarian 
tumor, not as a primary growth. 

Enchondroma and osteoma are secondary changes in pre-existing 
ovarian tumors. 

Angioma and lymphangioma are extremely rare. A congenital 
angioma is described by Orth. 

SARCOMA OF THE OVARY. 

In 66,190 malignant tumors of the ovary 96 were sarcomata. 
They are found at any period of life, from birth to old age. The 
periods of puberty and the menopause are the most frequent 
(Zangemeister). Doran found a sarcoma of the ovary in a seven 
months' foetus ; Heinrichs reported one in a woman aged seventy- 
four years. According to Temesvary, the average age of the patient 
is thirty-two years. Pfannenstiel finds sarcoma of the ovary most 
frequent between the ages of twenty-one and thirty. In 25 cases 
Pick finds 10 occurring before twenty years of age. 

Sutton says sarcoma of the ovary differs from sarcoma found else- 
where in that both ovaries are often simultaneously affected. In 



THE DIAGNOSIS OF DISEASES OF THE OVARIES. 371 

121 cases in the literature, I find 42, or about one-third of the 
number, in which both ovaries were involved. 

Many so-called fibroids of the ovary are undoubtedly sarcomata. 
Russel and Shenck described a sarcoma springing from the theca 
interna. In form they may resemble a large ovary or are very 
irregular and nodular. Their consistency varies from firm to soft 
and the color from pale gray to reddish-white. The rate of growth 
is variable, the softer tumors growing more rapidly. Chrobak saw 
a sarcoma of the ovary grow to the size of a five months' pregnancy 
in a few months. The entire ovary is usually involved, and both 
ovaries in about one-half of the cases. 

Both round and spindle sarcoma cells compose the tumor. About 
one-third are cystic. Sarcomatous degeneration of dermoid cysts 
is described. Metastasis occurs later in sarcoma than in carcinoma 
of the ovary. Metastatic growths are found in order of frequency 
in the peritoneum, omentum, wall of the stomach, pleura, lungs, 
uterus, liver, diaphragm, retrovaginal connective tissue, mediasti- 
num, tubes, intestine, and kidney (Temesvary). 

A myxomatous degeneration of sarcomatous tissue is occasionally 
observed. 

ENDOTHELIOMA OF THE OVARY. 

Marchand and Leopold first observed malignant new formations 
of the ovary arising from the endothelium of bloodvessels. They 
are also known to arise from the lymph vessels. Few have been 
recognized, but doubtless many pass for carcinoma and sarcoma. 

PAROVARIAN CYSTS. 

The parovarium consists of a series of tubules lying between the 
layers of the mesosalpinx. When the mesosalpinx is stretched and 
held between the eye and the light the tubules are seen as narrow 
cords running in parallel lines from the hilum of the ovary to a 
longitudinal tubule lying parallel to the tube and immediately 
beneath it (Gartner's duct). The tubules are lined with ciliated 
epithelium. The parovarium is homologous with the vasa affer- 
entia and epididymis of the testis. It is composed of the persistent 
excretory ducts of the Wolffian body. 

As a rule, there are twelve tubules. The tubule running parallel 
to the Fallopian tube and at right angles to the parovarian tubules 



372 SPECIAL DIAGNOSIS. 

is the duct of Gartner, which in exceptional cases may be traced to 
the vagina. 

Cysts arising from the parovarium, the so-called parovarian cysts, 
are of common occurrence. As the cyst develops the layers of the 
mesosalpinx are unfolded, the tube is crowded upward and runs 
over the cyst, and the ovary is crowded downward. The Fallopian 
tube is greatly elongated in large cysts, but the lumen is seldom 
obliterated. The wall of the cyst is at first thin and transparent, 
later thick and non-transparent. The epithelium lining the cyst is 
columnar and usually ciliated in the small cysts, while later the 

Fig. 175. 




Small parovarian cyst. This cyst has sprung from the parovarium, and is therefore entirely 
distinct from the ovary ; to the right is the hydatid of Morgagni suspended from a long, slen- 
der pedicle, which is attached to one of the fimbriated extremities of the Fallopian tube. The 
hydatid of Morgagni has been known to grow to the size of a small orange, and it then has the 
same general appearance as the parovarian cyst, but is distinguished from it by the fact that it 
springs from the extremity of the Fallopian tube. The Fallopian tube shows numerous points 
of expansion and constriction, one of them being at the isthmus ; this is known as the sal- 
pingitis isthmica nodosa, common in gonorrhceal salpingitis. Myoma and adenomyoma of 
the tube present much the same gross appearance. This condition of the tube is rarely found 
in connection with cysts of the parovarium. (Dudley.) 

epithelium is stratified and flat, In the very large cysts the 
epithelium may wholly disappear through pressure. The fluid con- 
tents is clear and watery, the reaction is slightly alkaline, and the 
specific gravity 1002 to 1010. 

JSTo parovarian cyst has been recorded in an individual under six- 
teen years of age (Sutton). They are supposed to form about 10 
per cent, of ovarian tumors. Parovarian tumors are rarely adher- 
ent ; they seldom suppurate, and are less liable to axial rotation 
than are ovarian cysts, because they are usually fixed and seldom 
have a pedicle. 



THE DIAGNOSIS OF DISEASES OF THE OVARIES. 373 

The Clinical Diagnosis of New Formations of the Ovary. 
In the diagnosis of ovarian tumors it is of the greatest importance 
to recognize a pedicle connecting the tumor to the horn of the 
uterus. The pedicle is composed of the Fallopian tube, broad 

Fig. 176. 




Parovarian cyst. Observe the ovary separate from the cyst and the long, stretched-out 
Fallopian tube which surrounds the cyst wall. (Dudley.) 



ligament, and ovarian ligament. A short, thick pedicle holds the 
tumor close to the uterus, while a long, slender pedicle permits 
considerable separation. The length and thickness of the pedicle 
are not proportionate to the size of the tumor. When, as occasion- 



374 SPECIAL DIAGNOSIS. 

ally happens, the tumor grows in the direction of the mesovarian 
and broad ligament, it becomes intraligamentous. An ovarian 
tumor may be partly within the broad ligament and partly within 
the free peritoneal cavity. Having grown between the layers of 
the broad ligament, the tumor may burrow to the left behind the 
sigmoid flexure, to the right behind the caecum, into the parametric 
tissue behind the uterus, or between the bladder and abdominal wall 
underneath the peritoneum. 

In discussing the diagnosis of ovarian tumors, we will adopt the 
classification of Winter, devised by him for convenience of descrip- 
tion. It is as follows : 

1. Small ovarian tumors, which lie wholly or in part within the 
pelvis. 

2. Medium-sized ovarian tumors, which have grown into the 
abdominal cavity, which have not grown beyond the size of a man's 
head, and have not risen to the arch of the ribs. 

3. Large ovarian tumors, which rise to the arch of the ribs and 
are in intimate relation to the liver, kidney, and spleen. 

The Diagnosis of Small Ovarian Tumors which Lie Wholly or in 
Part within the Pelvis. The tumor may be closely crowded to the 
uterus — so close that no pedicle is detected. It is always possible 
in a vaginal examination to insert the finger between the supra- 
vaginal portion of the cervix and the tumor. When the tumor lies 
behind the uterus it is especially difficult to separately outline the 
two. Ovarian cysts are round, the surface is usually smooth, and 
fluctuation is well-marked. They are not tender to pressure unless 
complicated by adhesions or other inflammatory lesions. 

Solid tumors are usually more uneven in outline and have a firm 
consistency. Cystic tumors with thick walls and surrounded by 
an inflammatory exudate may give the impression of solid tumor 
growths. The uterus may be crowded to the opposite side. 

Differential Diagnosis. To diagnose small tumors of the ovary 
from cystic degeneration, chronic ovaritis, hematoma, and abscess, 
it is necessary to consider the history of the onset and the clinical 
course. Sensitiveness to pressure speaks for inflammatory enlarge- 
ments, as does fixation. Inflammatory enlargements of the ovary 
do not show steady growth as do new formations, and, furthermore, 
they are more likely to be bilateral. In inflammatory swellings of 
the ovary the accompanying tube is often diseased, and evidences 
of pelvic peritonitis are frequently to be found. The effect of local 



THE DIAGNOSIS OF DISEASES OF THE OVARIES. 375 

applications is reduction of the size of inflammatory swellings of the 
ovary, while such treatments have no effect upon new-growths. 

Cystic degeneration of the ovary is very constantly associated with 
chronic ovaritis, and is to be distinguished from new formations of 
the ovary by its small size and tendency to be self-limited in growth. 
Such ovaries are rarely larger than a hen's egg. 

Uterine Fibroids. It is easy to mistake pedunculated subperi- 
toneal fibroids of the uterus for tumors of the ovary. 

Uterine Fibroids. Ovarian Cysts. 

1. Rarely occur early in life. 1. May occur in infancy. 

2. Rarely grow after the menopause. 2. Often continue to grow after the meno- 

pause. 

3. Rate of growth is slow. 3. Rate of growth is usually more rapid. 

4. Consistency usually firm. 4. Fluctuating. 

5. Intimately attached to the uterus. 5. Less intimately associated with the 

uterus. 

6. Tumor may be attached to any portion of 6. Tumor connected with the uterine horn. 

the uterus. 

7. Pedicle usually short and thick. 7. Pedicle may he long and slender. 

8. Uterus usually increased in length. 8. No increase in the length of the uterus. 

9. May find both ovaries normal. 9. One or both ovaries abnormal. 

10. Venous murmur heard in 50 per cent, of 10. Venous murmur seldom heard. 

large fibroids. 

11. Menorrhagia common. 11. Not common. 

12 Functions of the bladder and rectum 12. Not often disturbed, 
often disturbed. 

It must be remembered that uterine fibroids may appear to fluc- 
tuate similarly to a cyst with gelatinous fluid. When doubt exists 
after all of the above points are considered, an exploratory incision 
should be made. 

Tubal Pregnancy. See respective chapter. 

Serous perimetric exudates may become sharply circumscribed, 
slightly or not at all tender to pressure, and may fluctuate from 
contained fluid. In the early stage the exudate may collect in the 
pouch of Douglas, and from its form and consistency it may be mis- 
taken for an ovarian tumor. Such exudates are rounded below and 
flat above, while ovarian cysts are round throughout their entire 
circumference. The consistency may show variations at different 
points, while in ovarian cysts it is usually uniform throughout. The 
exudate blends with the surrounding structures, and is inseparably 
connected with the uterus. 

The history of infection, the rapid development of the mass, and 
the tendency to remain stationary, or to decrease in size, are impor- 
tant factors in the differential diagnosis of perimetric exudates 
from ovarian cysts. 



376 SPECIAL DIAGNOSIS. 

Parametric exudates can usually be differentiated from ovarian 
cysts by the history of infection. This will point to an inflamma- 
tory origin. The location of the mass in the connective tissue in 
close proximity to the vaginal wall is characteristic of pelvic cellu- 
litis. Ovarian tumors lie on a higher level. The consistency of 
an inflammatory exudate changes from time to time, becoming 
firmer and irregular, while the consistency of ovarian cysts is 
constant. It is often possible to palpate both ovaries apart from 
the pelvic exudate. 

The intimate connection with the uterus, the ill-defined outline, 
the immobility and tenderness to pressure, the history of infection? 
and the sudden development of the mass, together with its tendency 
to become smaller as time goes on, are significant points in favor 
of the diagnosis of a pelvic exudate. 

Pericecal Abscess. A suppurating cyst of the ovary may be con- 
fused with an abscess about the caecum. A history of one or more 
attacks of appendicitis and existing intestinal disorders will be sug- 
gestive. The abscess is largely confined to the right iliac region, and 
extends downward to the uterus rather than upward from the uterus. 

Retro-uterine hematocele occupies the pouch of Douglas, and may 
be so moulded as to suggest an ovarian tumor. A hematocele is 
less tense and elastic, and does not fluctuate. There is no attach- 
ment by a pedicle to the horn of the uterus, and it may be possible 
to palpate both ovaries apart from the mass. A history of ruptured 
tubal pregnancy is often elicited. An exploratory puncture or 
incision will disclose the blood. 

Intraligamentous hematoma in its early development occupies a 
position altogether impossible for an ovarian tumor, and, later, as 
it dissects around the uterus, it cannot be confounded with an 
ovarian tumor. The low situation of the mass, its ill-defined out- 
line, the absence of fluctuation, its tendency to become smaller 
instead of progressively enlarging, and, finally, an exploratory 
puncture or incision will determine the diagnosis. There is usually 
a history of ectopic pregnancy with rupture of the gestation sac. 

A retroflexed pregnant uterus has been mistaken for an ovarian 
cyst. The usual signs of pregnancy are to be considered. In 
ovarian cysts it is possible to have amenorrhea, enlargement of the 
niammse, secretion of colostrum, discoloration of the cervix and 
vagina, and nausea. These signs, together with a rapidly growing 
abdominal tumor, might suggest pregnancy. 



THE DIAGNOSIS OF DISEASES OF THE OVARIES. 377 

The rate of growth of a pregnant uterus is more rapid than that 
of an ovarian cyst. Its consistency is soft and elastic, as contrasted 
with the tense elasticity of an ovarian cyst. So long as there is a 
suspicion of pregnancy the sound should not be employed. When 
in doubt as to the diagnosis, and immediate interference is not 
demanded, it is well to keep the patient under observation for 
several weeks to note the progress of the tumor and the develop- 
ment of positive signs of pregnancy. 

THE DIAGNOSIS OF OVARIAN TUMORS OF MEDIUM SIZE. 

A tumor lying at the brim of the pelvis that is round or oval, 
sharply outlined and fluctuating, is in all probability an ovarian 
cyst. If it can be demonstrated that the tumor is attached to the 
horn of the uterus by a pedicle, the diagnosis is confirmed. It is 
most essential to recognize the pedicle, and this is usually possible 
where the conditions for examination are favorable. Where the 
pedicle is difficult to palpate, Hegar advises traction on the cervix 
by a tenaculum while a recto-abdominal examination is carried out. 

Winter further advises traction on the tumor by an assistant, as 
shown in Fig. 10. In this manner the pedicle is made taut and 
can be more readily recognized. Where the pedicle cannot be 
palpated, the diagnosis must rest upon the consistency aud general 
outline of the uterus. 

Pregnancy in the second and third trimester can only be confounded 
with an ovarian tumor when there is no evidence of the presence of 
a foetus. There will be still greater uncertainty in the diagnosis 
when it is not possible to demonstrate the direct continuity of cervix 
and body because of the high position of the uterus. 

The uterine souffle is seldom heard in ovarian cysts and will 
speak for a pregnant uterus or a solid tumor. The finding of the 
round ligaments running to the tumor will establish the diagnosis. 

Advanced Ectopic Pregnancy. The history of pregnancy, together 
with the finding of an abdominal tumor of unequal soft consistency 
and absence of fluctuation, will suffice for the exclusion of an ovarian 
cyst. Where the foetus is living it is scarcely possible to mistake 
the tumor for an ovarian cyst. With the death of the foetus all 
signs of pregnancy may disappear. The uterus, in an ovarian cyst, 
is normal in size, while in advanced ectopic pregnancy it fairly 
resembles a pregnant uterus at the third month. 



378 SPECIAL DIAGNOSIS. 

A distended bladder may resemble an ovarian cyst in general out- 
line, position, and consistency. In every pelvic examination for 
whatever lesion, it is always advisable to make sure that the bladder 
is empty. If this rule is observed there will be no question as to 
the differential diagnosis of an ovarian cyst from a greatly distended 
bladder. When such a question arises the catheter will obviate all 
possible error. 

Tumors of the omentum rarely simulate ovarian tumors. They 
are seldom so sharply circumscribed and rounded, and are not con- 
nected to the uterus by a pedicle. The finding of the ovaries apart 
from the tumor will exclude the possibility of an ovarian tumor. 
Omental cysts have been tapped for ovarian cysts. 

Echinococcus cysts of the pelvis form a rounded cystic tumor 
that closely resembles an ovarian cyst. The presence of a tumor 
of the liver speaks in favor of echinococci, but an absolute diagnosis 
is only made by an exploratory puncture and the finding of the 
hooklets. 

Parovarian cysts have thin walls and are less tense than ovarian 
cysts. Unless the ovary can be palpated distinct from the cyst a 
diagnosis cannot be made with certainty. 

Phantom tumors of the abdominal wall, caused by muscular con- 
traction, may simulate an ovarian cyst in form and consistency. 
The swelling has no connection with the uterus and will disappear 
under anaesthesia. 

THE DIAGNOSIS OF LARGE OVARIAN TUMORS FILLING 
THE ABDOMINAL CAVITY. 

It is often quite impossible to palpate the pedicle because of the 
close proximity of the large tumor to the uterus. When it is 
demonstrated that the swelling is a cystic tumor and not free fluid, 
the diagnosis of an ovarian cyst is highly presumptive, because it is 
most unusual for a cystic tumor of such size to grow from any other 
source than the ovary. The superficial veins of the abdominal wall 
are distended, and markings resembling stride gravidarum are 
usually seen over the abdomen. The percussion note is dull over 
the swelling, and tympanitic in the flanks, and over the stomach 
where the intestine and stomach have been crowded by the tumor. 
Changing the position of the patient does not alter the outline of 
the area of dulness as it does in free ascites. 



THE DIAGNOSIS OF DISEASES OF THE OVARIES. 379 

Fluctuation is easily demonstrated. Because of the great disten- 
tion of the abdomen it is difficult to outline the uterus. When 
pregnancy can be excluded the uterine sound will determine the 
position of the uterus. In cysts of extreme size the upper border 
lies beneath the sternum and ribs, bulging them forward ; the 
tympanitic note of the transverse colon and stomach is lost. The 
splenic dulness is lost, the liver dulness cannot be defined from that 
of the tumor, and the heart and lungs are pressed upward. The 
abdomen is symmetrically enlarged, hence measurements are of no 
value in the largest cysts. Those of smaller size present an asym- 
metrical enlargement which can be demonstrated by inspection and 
by certain measurements. These measurements are taken from the 
umbilicus to the anterior superior spine of the ilium, and from the 
linea alba to the spine of the vertebrae. A comparison of the meas- 
urements of the two sides will afford reliable information. Auscul- 
tation is of little service. A bruit is sometimes heard, and will 
serve to differentiate the cyst from ascites. 

Differential Diagnosis. Free ascites is very often mistaken for 
large ovarian cysts. Cases occur where a diagnosis cannot be 
made until the abdomen is opened. Still greater difficulty arises 
when an ovarian cyst is associated with ascites. Much can be 
ascertained from inspection of the distended abdomen. 

Ascites. Laege Ovarian Cyst. 

1. Diseases of the heart, lungs, liver, and 1. Absent. 

peritoneum to account for the presence 
of the fluid. 

2. Rapid development. 2. Development usually slow. 

3. Inspection of abdomen. 3. Inspection of abdomen. 

a. Enlargement symmetrical. a. Enlargement asymmetrical unless the 

entire abdomen is filled. 

b. Flattening anteriorly and bulging in b. Round anteriorly and flat in the flanks 

the flanks with patient on her back. with patient on her back. 

c. Lower portion of abdomen bulges and c. No change in the outline of the tumor 

epigastrium is flattened with patient by change of position of the patient, 

erect. 

d. Navel prominent and thin. d. Navel not prominent. 

e. Costal arch does not bulge. e. Costal arch bulges. 
A. Percussion of abdomen. 4. Percussion of abdomen. 

a. Dulness in flanks. a. Dulness over abdominal prominence. 

b. Tympany in median line. b. Tympany in flanks and epigastrium. 

c. Change of area of dulness by change c. No such change. 

of position of patient. 

•5. Palpation of abdomen. 5. Palpation of abdomen. 

a. No outline of tumor can be palpated. a. Outline palpated. 

b. Fluctuation in all vaginal fornices. b. More limited. 

6. Exploratory puncture. 6. Exploratory puncture. 

Contain serous fluid. Contains serum or mucus. 

7. Hydragogues and diuretics temporarily 7. Have no effect. 

improve the condition. 



380 



SPECIAL DIAGNOSIS. 



Fig. 177. 




-.■:.. ■ 



V///////M INTESTI 
/^DULNESSv^ RESONA 





Free fluid in the abdominal cavity. The dark lines show tbe area of dulness on percussion 
with the patient lying on her back. 



THE DIAGNOSIS OF DISEASES OF THE OVARIES. 381 



Fig. 178. 







Large ovarian cyst. The dark lines show the area of dulness on percussion in any position 
the patient may assume. 



382 SPECIAL DIAGNOSIS. 

The percussion note is of greatest value in differentiating free 
from encysted fluid. The area of dulness increases as the fluid 
collects, and is last to disappear in the epigastrium. In ascites of 
extreme grade there may be no area of tympany, and the same may 
be true of very large ovarian cysts. If the mesentery is short, the 
tympanitic note disappears early ; if long, so as to permit the bowels 
to float on the surface of the ascitic fluid, or to be crowded in 
advance of the cyst, the tympany can be demonstrated until the 
abdomen is overdistended. 

Certain fallacies must be guarded against. A very short mesen- 
tery or the presence of adhesions may confine the intestine to the 
flanks in free ascites and give a tympanitic note in this region. In 
ovarian cyst the bowel may be adherent to the anterior abdominal 
wall and give a tympanitic note in the median line. Gas generated 
within the cyst may give a tympanitic note. Again, the absence of 
gas within the bowel may give a dull note where tympany would 
otherwise be found. 

In an ovarian cyst the percussion note is always dull over the 
tumor, whether the percussion is superficial or deep, while in ascites 
superficial percussion may be tympanitic and deep percussion dull. 

It is especially difficult to differentiate between ascites and a 
thin-walled cyst, such as a large parovarian cyst. In the latter 
the fluid may gravitate to the dependent portions of the abdomen, 
and it may not be possible to outline the tumor by palpation. An 
exploratory incision may alone clear up the diagnosis. 

As an aid to the differential diagnosis of ascites and ovarian cysts, 
Landau advises putting the patient in the lithotomy position and 
elevating the hips. If there is a large quantity of free fluid in the 
abdominal cavity, the uterus, in an abdomino- vaginal manipulation, 
may be demonstrated to lie upon a water cushion. 

Pancreatic Cysts. No confusion should arise in the early develop- 
ment of pancreatic cysts. They take their origin in the region of 
the pancreas and grow from above downward. The most promi- 
nent portion of the tumor is located in the region of the navel. 

It is possible for a small or moderate-sized ovarian cyst with a 
long pedicle to occupy a similar position. Such a cyst is usually 
more movable than a pancreatic cyst, and the demonstration of 
its attachment to the uterus by a pedicle will determine the diag- 
nosis. 

In doubtful cases an exploratory puncture, together with a chem- 



THE DIAGNOSIS OF DISEASES OF THE OVARIES. 383 

ical analysis of the aspirated fluid, will identify a pancreatic cyst. 
The danger of perforating the stomach is to be borne in mind. 

Splenic Tumor. It is possible for a tumor of the spleen to extend 
to the inlet of the pelvis, and when cystic (echinococcus) an ovarian 
cyst may be diagnosed. Most splenic tumors are solid, and these 
are not likely to be mistaken for ovarian tumors. A splenic tumor 
grows from above downward, while an ovarian tumor grows from 
below upward. The finding of a pedicle connecting the tumor with 
the horn of the uterus identifies it as ovarian in origin. An analysis 
of the blood will often disclose the nature of a splenic tumor (splenic 
leukaemia, malaria). The notched border and the respiratory move- 
ments of the spleen are significant. A number of cases has been 
reported in which a spleen of about normal size has occupied the 
pelvis and has been mistaken for solid tumors of the ovary. It is 
important in all such cases to seek for a pedicle connecting the 
tumor with the horn of the uterus. As a last resort an exploratory 
incision may be made. 

Tumors of the Liver. It is possible for tumors of the liver to 
reach to the inlet of the pelvis. An ovarian tumor, because of its 
great size or long pedicle, may reach to the right costal arch and the 
tumor and liver become one inseparable mass. 

A uniform enlargement of the liver should be recognized by its 
sharp lower border and by the characteristic fissure separating the 
right from the left lobe. The mass should move with respiration, 
a fact not observed in ovarian tumors. An irregular enlargement 
of the liver, as from echinococcus cysts, abscess, and new forma- 
tions, is more likely to be mistaken for an ovarian tumor than is a 
uniform enlargement. Here, as at all times, it is essential to deter- 
mine the relation of the tumor to the uterus, whether or not there 
exists a pedicle. In pedunculated tumors of the liver the greatest 
mobility is at the lower portion of the growth, while in freely mov- 
able ovarian tumors the greatest mobility is at the upper portion of 
the tumor. 

Fatty Tumors. Enormous fatty tumors may spring from the 
omentum and subserous tissue, and suggest the possible presence 
of ovarian tumors. 

A distended gall-bladder containing eleven pints of fluid was 
operated upon by Lawson Tait, who mistook it for an ovarian cyst. 

A chylous cyst of the mesentery may attain an enormous size, 
and closely simulate an ovarian cyst. 



384 SPECIAL DIAGNOSIS. 

Obesity. A very thick abdominal wall may suggest the presence 
of an ovarian tumor. It may be impossible to say that an ovarian 
cyst does not exist without making an exploratory incision. 

Allantoic or urachus cysts may give rise to suspicion of an ovarian 
cyst. They may attain a large size, and are always found in the 
median line between the abdominal wall and peritoneum. 

Hydronephrosis has been mistaken for ovarian cysts. A hydro- 
nephrosis may occupy the pelvis and an ovarian tumor may occupy 
the region of the kidney. Moreover, a hydronephrosis and an 
ovarian tumor may coexist. 

The characteristic physical signs of renal tumors can usually be 
relied upon. The colon lying in front of the kidney gives a tym- 
panitic note on light percussion. In exceptional cases the bowel 
may lie in front of an ovarian cyst. In hydronephrosis the tumor 
may intermit, and such diminution in size is accompanied by an 
abundant flow of urine. Examination of the urine may disclose 
important facts. It is possible for an ovarian cyst to rupture, and 
this in turn be followed by diuresis. 

The ovarian cyst when large and fixed may cause hydronephrosis 
by pressure upon the kidney or ureter. 

The diagnosis of bilateral ovarian tumors is readily made when 
from either tumor a pedicle is traced to the uterine horns. 
The smaller the tumor the easier the diagnosis. In very large 
tumors the diagnosis may be impossible. When in the absence of 
pregnancy and in the presence of a large cystic tumor of the abdomen 
the menses are suppressed, a bilateral ovarian tumor is suspected. 
The two tumors are rarely of the same size, and rarely lie on the 
same level. A furrow may separate the two, and two separate and 
distinct percussion waves may be elicited. The tumors may be 
moved separately by bimanual manipulation. Not infrequently the 
diagnosis is deferred until an exploratory incision has been made. 

INTRALIGAMENTOUS DEVELOPMENT OF OVARIAN TUMORS. 

It is not always possible to recognize an intraligamentous tumor 
of the ovary without opening the abdomen. Such tumors lie within 
the two layers of the broad ligament in close proximity to the uterus 
and are usually firmly fixed. No pedicle can be palpated. In very 
exceptional cases the tumor will distend the broad ligament and 
draw it out into a broad pedicle. Such tumors have some degree 



THE DIAGNOSIS OF DISEASES OF THE OVARIES. 385 

of mobility. Intraligamentous tumors of the ovary rarely grow 
to a large size. The uterus and tumor appear as one mass, or 
the uterus may be distinctly outlined from the tumor. In excep- 
tional cases the tumor may burrow beneath the peritoneum behind 
or to the front of the uterus. When bilateral the uterus may be 
lifted out of the pelvis. 

Ovakian Cysts. Parovarian Cysts. 

1. Develop from the oiiphoron. 1. Develop from the parovarium. 

2. Commonly multilocular. 2. Usually unilocular. 

3. May reach enormous size. 3. Seldom large. 

4. Growth usually rapid. 4. Usually slow. 

5. Usually pedunculated and movable. 5. Rarely pedunculated and usually fixed. 

6. Adhesions about cyst common. 6. Adhesions not common. 

7. Tapping not curative. 7. Often curative. 

8. Character of contents : contains albumin ; 8. Character of contents : little or no albu- 
is mucinous or thin and watery ; clear and min ; clear, watery fluid of sp. gr. 1003 to 
transparent, or coffee colored. 1010. 

9. Papillomatous growths common. 9. Not common. 

10. Rarely intraligamentous. 10. Always. 

11. Tendency to become malignant. 11. Seldom becomes malignant. 

12. Rarely self- limited in growth. 12. Self-limited in growth. 

13. No ovary visible. 13. Ovary attached to the periphery of cyst. 

14. Bloodvessels seldom seen to radiate over 14. Large, radiating bloodvessels frequently 
the surface of the cyst. seen on the surface of the cyst. 

Adherent Tumors of the Ovary. From an operative point of view 
it is very important to recognize the presence of adhesions. It is 
manifestly more difficult to recognize adhesions in large cysts which 
have little or no range of motion than in small cysts which under 
ordinary conditions are freely movable. Adhesions are recognized 
by the immobility of the tumor, its greater or less degree of tender- 
ness, and, in exceptional cases, by palpating the adhesions in a con- 
joined examination. 

In large cysts the respiratory excursions are less marked when 
adhesions are present. It may be impossible to determine the 
degree of mobility unless an anaesthetic is administered. When the 
cyst is adherent to the parietal peritoneum the abdominal wall 
moves with the cyst ; friction sounds and fremitus may be heard. 
Adhesions to the mesentery and intestine may permit free mobility 
of the tumor. 

Torsion of the Pedicle. It is of the greatest importance to make 
an early diagnosis of torsion of the pedicle. Delay in recognizing 
the condition may terminate disastrously. 

Certain conditions are recognized as predisposing to this event, 
namely, a long pedicle, ascitic fluid, sudden alterations in the intra- 
abdominal pressure from overexertion, falls, and blows, a growing 

25 



386 



SPECIAL DIAGNOSIS. 



pregnant uterus, and the emptying of a pregnant uterus. Torsion 
of the pedicle is said to occur in about 10 per cent, of ovarian and 
parovarian tumors. 

When both ovaries are cystic the liability to torsion is about as 
great as when a single cyst complicates pregnancy. 

Twisting of the pedicle occurs in all ages and in all kinds of 
ovarian tumors. Thornton observed it in a thirteen-year-old girl, 
and Potter in a woman, aged eighty-three years. Dermoid cysts 
are particularly liable to this accident. 




An adherent multilocular cyst crowding the uterus into extreme anteversion. 



As a result of torsion of the pedicle, many grave complications 
may arise. Hemorrhage into the cavity of the cyst may rapidly 
distend it, even to the point of bursting, and may prove fatal. 
Gangrene of the cyst will rapidly follow when the circulation is 
completely shut off ; peritonitis is then inevitable. If adhesions 
convey sufficient blood to the cyst, gangrene will not follow and the 
cyst may remain intact. It is possible for the cyst to be entirely 
severed from the uterus. In order that the cyst may not undergo 



THE DIAGNOSIS OF DISEASES OF THE OVARIES. 387 

speedy destruction, adhesions must convey a sufficient supply of 
blood. The tightness of the twist varies with the thickness of the 
pedicle. Tumors of medium size are most liable to this accident. 

The diagnosis cannot be made with certainty. Having previously 
recognized a pedunculated tumor of the ovary, torsion of the pedicle 
will be suspected, when the patient is seized with severe pain in the 

Fig. 180. 




Ovarian hydrocele, natural size. The tortuous, retort-shaped Fallopian tube connects the 
tumor with the uterus. (Dudley.) 



region of the tumor, and at the same time the tumor increases in 
size and is tender to pressure. Collapse may follow immediately 
upon the twisting of the pedicle. An absolute diagnosis must be 
reserved for an exploratory incision. Operative interference must 
be advised upon a provisional diagnosis ; the expectant plan of 
treatment is not to be followed. 



388 SPECIAL DIAGNOSIS. 

A limited degree of torsion may cause no symptoms ; there is 
pain of variable intensity followed by symptoms of peritonitis, 
including fever, rapid pulse, tympany, and abdominal tenderness. 
Peritonitis complicating ovarian cysts is most often the result of 
secondary infection of the cyst. 

Torsion of the pedicle of an ovarian tumor must be differentiated 
from hepatic colic, renal colic, intestinal obstruction, strangulated 
hernia, appendicitis, ruptured tubal pregnancy, and rupture of a 
sactosalpinx. 

Rupture of an ovarian cyst results from direct violence, torsion of 
the pedicle, degeneration of the cyst wall, hemorrhage within the 
cyst and in the wall of the cyst. Spontaneous rupture from thin- 
ning of the cyst wall has been reported. 

"When the cyst ruptures there is a feeling of relief from pressure ; 
the cyst is no longer evident, but if sufficient fluid has escaped the 
contents may be recognized free in the abdominal cavity. From 
absorption of the contained fluid the temperature may be slightly 
elevated and the bowels and kidneys become unusually active. 
The cyst may rapidly refill. 

Leakage of the cyst is a term implying a slow and limited empty- 
ing of a cyst into the peritoneal cavity. The daughter cysts, which 
so often bulge on the surface of the parent cyst, have an extremely 
thin wall, which may give way at some point and permit the con- 
tents to be discharged into the peritoneal cavity. Secondary cysts 
also rupture into the parent cyst, and in this manner a multilocular 
cyst may be converted into a unilocular cyst. 

Rupture of the cyst may occasion hemorrhage that is either 
confined within the cyst or that escapes into the free peritoneal 
cavity. The hemorrhage may prove fatal ; this is particularly true 
of rupture following upon torsion of the pedicle. The escape of the 
fluid from the cyst is often hindered by the plugging of the rent 
with a daughter cyst. 

Rupture of an ovarian cyst into hollow viscera is possible. 
Dermoid cysts are particularly likely to adhere to the bowel and 
to subsequently rupture into it ; such cysts are invariably in- 
fected. 

Hemorrhage into the cyst is the common result of torsion of the 
pedicle, and the symptoms are usually masked by those caused by 
the torsion. Puncture and direct violence are additional causes of 
hemorrhage. 



THE DIAGNOSIS OF DISEASES OF THE OVARIES. 389 

A moderate hemorrhage may cause no clinical symptoms. When 
the loss of blood is considerable the symptoms are those of internal 
hemorrhage, together with a rapid increase in the size of the tumor, 
pain, and high tension in the cyst. 

Suppuration of an ovarian cyst was formerly believed to follow 
tapping and the accidental admission of air. This is possible, but 
more often suppuration occurs independently of such events. 
Dermoid cysts are particularly liable to suppuration. The infected 
cysts are invariably adherent to the bowel, bladder, or vagina, and 
through these adhesions the infection is conveyed to the cyst. 

In acute cases the patient dies from septic infection, unless opera- 
tive interference is instituted. The symptoms of acute suppuration 
are characteristic. The temperature is elevated and irregular, the 
pulse is rapid and feeble, exhaustion and emaciation rapidly develop. 
The cyst increases in size, and is very tender to pressure. Sutton 
has observed the temperature to become subnormal in long-standing 
cases with foul-smelling pus. 

When gas generates in the cyst the dull percussion note gives 
place to tympany. After suppuration the cyst may discharge its 
contents into the bowel, bladder, vagina, rectum, peritoneal cavity, 
or through the abdominal wall. 

When a fistulous communication is established between the cyst 
and a hollow viscus, or the abdominal wall, the discharge of pus 
may be prolonged indefinitely, and the patient finally become 
exhausted. Fragments of bone, teeth, and hair have sloughed into 
the bladder from an adherent dermoid cyst. These fragments may 
become the nuclei of vesical calculi. 

It is most unusual for such fistula? to close spontaneously. The 
infection frequently travels to the cyst by way of the Fallopian 
tube. From an infected tube adhesions may develop between the 
cyst and the omentum, bowel, bladder, and abdominal wall. In a 
similar manner the appendix is the starting-point of an infection in 
and about the cyst. Adhesions between the appendix and cyst must 
be looked for in the course of the removal of the cyst, otherwise 
death may be caused by tearing through the appendix and bowel. 

The diagnosis of malignant degeneration of an ovarian 
tumor is of the utmost importance, but unfortunately cannot be 
made with certainty without a microscopic examination. 

Bilateral ovarian tumors of the ovary are often malignant, but 
all forms of benign tumors of the ovary are occasionally bilateral. 



390 SPECIAL DIAGNOSIS. 

The presence of ascites is also suggestive of malignancy, yet malig- 
nant tumors of the ovary may exist without ascites, and all forms 
of new-growths of the ovary may be associated with ascites ; this is 
particularly true of papillomatous growths. 

The most suggestive signs of malignant degeneration of new- 
growths of the ovary are rapid growth, immobility of the tumor, 
and their firm, nodular character. Partial development within the 
broad ligament is also said to be suggestive of malignant degenera- 
tion. Metastatic growths may be found on the peritoneum and in 
the viscera. Finally, an exploratory incision will be required in 
many cases, and even then the diagnosis must sometimes be 
deferred for a microscopic examination. The consideration of the 
age of the patient is not of great importance in that malignant 
tumors of the ovary are known at all ages from the time of puberty. 

OVARIAN TUMORS COMPLICATING PREGNANCY. 

All forms of ovarian tumors may complicate pregnancy. Prob- 
ably the most frequent are the dermoids, because they occur early 
in life, grow slowly, and are very often fixed in the pelvis, where 
they offer obstruction to labor. 

The dangers to be apprehended during pregnancy are : 

1. Axial rotation of the tumor. 

2. Rupture of the cyst. 

3. Incarceration of the tumor in the pelvis. 

4. Impediment to respiration when large. 

5. Interference with the functions of the abdominal viscera from 
pressure. 

The dangers to be apprehended in labor are : 

1. Rupture of the cyst. 

2. Torsion of the pedicle. 

3. Suppuration of the cyst. 

4. Hemorrhage into the cyst. 

5. Rupture of the uterus and vagina. 

6. Interference with the passage of the foetus and with contrac- 
tion of the uterus in the third stage. 

Very often pregnancy and labor are not affected by the presence 
of an ovarian cyst. 

The diagnosis of the variety of ovarian tumors is only possible to 
a limited degree. The diagnosis between a cystic and solid tumor 



THE DIAGNOSIS OF DISEASES OF THE OVARIES. 391 

is seldom difficult. Fluctuation and an exploratory puncture will 
demonstrate the presence of fluid. 

It is manifestly impossible to differentiate clinically a uniloc- 
ular from a ni unilocular cyst. When smooth and regular in outline 
and consistency the cyst is assumed to be unilocular ; when nodular 
and irregular in consistency and when of enormous size it is 
assumed to be multilocular. A positive statement can only be 
made when the cyst is opened. 

Dermoid cysts are suspected when a slow-growing tumor, irreg- 
ular in outline and consistency, is observed early in life. 

Papillary cysts are suspected when the new-growths of the ovary 
are bilateral or intraligamentous, when ascites accompanies them, 
and when they are irregular in outline. 

Exploratory puncture of ovarian cysts was at one time universally 
employed, not only as a diagnostic measure, but for the purpose of 
emptying the cyst. The procedure has given way to the more sat- 
isfactory and equally safe method of exploratory incision. The 
fluid removed by aspirating may be so characteristic as to permit a 
diagnosis not only of the presence of an ovarian cyst, but of the 
particular variety. Mucinous fluid is characteristic of a pseudo- 
mucinous multilocular cyst of the ovary. The serous fluid of an 
ovarian cyst cannot be recognized from that of ascites or hydro- 
nephrosis. Contrary to former belief, the chemical and microscopic 
analyses are of no special value in differentiating the serous contents 
of ovarian cysts from ascites. The dangers involved in an explora- 
tory puncture of a cyst are infection of the contents, puncture of a 
bloodvessel followed by alarming hemorrhage, injury to adherent 
coils of bowel, escape of the contents of the cyst into the peritoneal 
cavity, and finally, though rarely, torsion of the pedicle. 

Exploratory incision may be regarded as a safer and more satis- 
factory method. The incision is to be made after the usual prepara- 
tion for abdominal section. 

FATE OF OVARIAN TUMORS. 

1. Parovarian cysts are self-limiting in their growth, and if they 
rupture it is possible that they will never refill. 

2. Ovarian cysts may disappear after rupture and torsion of the 
pedicle, though this is exceptional. 

3. Simple cysts of the ovary are self -limited in their growth, but 
m unilocular proliferating cysts are not. According to Olshausen, 



392 SPECIAL DIAGNOSIS. 

proliferating multilocular cysts will cause death from pressure 
within three years. 

4. Proliferating cysts of the ovary cause death by : 

a. Exhaustion due to interference with nutrition, sleep, and 
breathing. 

b. Cystitis and pyelitis. 

c. Pressure on the ureters, causing hydronephrosis, pyonephrosis, 
and uraemia. 

d. Intestinal obstruction. 

e. Suppuration and gangrene of the cyst. 
/. Peritonitis. 

g. Hemorrhage. 

h. Impediment to labor. 



CHAPTEK XXX. 

THE DIAGNOSIS OF PERITONITIS. 

The pelvic peritoneum covers the concave surface of the floor of 
the pelvis. From the anterior abdominal wall it is reflected to the 
fundus of the empty bladder, passing downward and backward 
to the posterior surface of the bladder and reflected on the an- 
terior surface of the uterus at about the level of the internal os. 
It closely adheres to the body of the uterus in front and behind, 
and to a point about one-half inch below the attachment of the 
vagina to the cervix. From this point it is reflected upon the 
rectum. Between the bladder and uterus the peritoneum forms 
the so-called vesico-uterine pouch. Between the uterus and rectum 
is a much deeper and more important pouch, the cul-de-sac of 
Douglas, which is defined as follows : the upper lateral boundaries 
are the uterosacral ligaments, the lower lateral boundaries and the 
floor are of peritoneum, the anterior boundary is the supravaginal 
portion of the cervix and the upper half inch of the vagina, and 
the posterior boundary is the rectum and sacrum covered with 
peritoneum. 

At the sides of the uterus the peritoneum forms two laminae 
running outward and backward to the sides of the pelvis to a point 
immediately in front of the sacro-iliac synchondrosis. These laminae 
are closely approximated above, where they envelop the Fallopian 
tubes and are widely separated below by loose connective tissue. 
These folds are known as the broad ligaments. They enclose the 
Fallopian tubes, the parovarium and an abundance of connective 
tissue at the base. The peritoneum is reflected upon the side walls 
of the pelvis. Over the bladder it is readily separated ; over the 
uterus it is closely adherent save at the lower portion, where it can 
be easily stripped from the organ. The upper part of the rectum 
is closely invested with peritoneum ; the lower portion is loosely so. 

GENERAL PERITONITIS. 

In general peritonitis the entire peritoneum from the diaphragm 
to the floor of the pelvis is involved in the inflammatory process. 



394 SPECIAL DIAGNOSIS. 

We will here consider the subject from a gynecological stand- 
point. Schroeder speaks of : 

1. Benign non-infectious peritonitis arising from mechanical causes, 
such, for example, as the escaped fluid and papillomata from an 
ovarian cyst. 

There are none of the clinical manifestations of sepsis, and all 
general and local clinical evidences of peritonitis may be wanting. 
In the abdomen there are usually pain, tenderness, and tympany. 

2. Septic peritonitis arises from the invasion of the peritoneum 
by septic micro-organisms. These organisms gain access to the 
peritoneum from infected tubes, ovaries, and pelvic cellular tissue ; 
also, from wounds incident to labor and surgical operations. 

In this form there are present the general and local clinical evi- 
dences of septic infection. The pelvis and abdomen are tender to 
pressure ; nausea, vomiting, and hiccoughing are usually present ; 
the temperature rises, and the pulse becomes rapid, weak, and 
irregular. In a streptococcus infection death almost invariably 
ensues within a week. The general symptoms of septic infection 
are out of proportion to the local evidences. 

Putrid, saprophytic peritonitis due to infection from the bacterium 
coli and anaerobic bacteria forms a clinical picture which varies in 
its general and local signs. 

There may be few or no local manifestations, but a profound 
general intoxication is invariably present. Menge says that pain- 
lessness and fetid odor to the breath are evidences of colon infection. 

Gonorrhoeal peritonitis unquestionably exists, but the cases are 
few. Cushing and Wertheim were first to demonstrate that gonococci 
can live upon the human peritoneum. Hunner and Harris, of Johns 
Hopkins, recently reported six cases of gonorrhoeal peritonitis. 

The general symptoms of infection develop quickly and often to 
an alarming degree, but the course is usually brief and the prog- 
nosis is relatively good. 

In all forms of general peritonitis all of the usual signs of peri- 
tonitis may fail, and the diagnosis must be held in abeyance until 
the abdomen is explored. 

Tympany is the earliest and most reliable symptom. Pain can- 
not be relied on ; it may be altogether absent. Nausea and vomit- 
ing are rather constant symptoms, though unreliable in making a 
diagnosis. While the temperature is usually elevated it may be 
normal or subnormal, and does not correspond with the extent of 



THE DIAGNOSIS OF PERITONITIS. 395 

involvement of the peritoneum. The character of the pulse is a 
more reliable guide to the general condition of the patient than is 
the temperature. In direct proportion to the general septic infec- 
tion the pulse is increased in rate and becomes irregular in rhythm 
and force. Unrest and anxiety are depicted upon the face. 

TUBERCULOUS PERITONITIS. 

This disease runs an acute or chronic course with a low grade of 
fever. A fluid exudate commonly occupies the abdominal cavity. 
More often the fluid is free, but at times it is encysted between 
adherent coils of bowel. 

Less often the exudate is fibrinous or serofibrinous, resulting in a 
shortening of the mesentery and adhesion of the peritoneal surfaces 
of the abdominal viscera. Tubercles stud the peritoneal surface. 

The diagnosis may be extremely uncertain or impossible without 
an exploratory incision. In the absence of other causes, such as 
puerperal and gonorrheal infection, and in the presence of tubercu- 
losis elsewhere in the body, the tuberculous nature of the lesion is 
suspected. 

CARCINOMATOUS PERITONITIS. 

Carcinomatous peritonitis arising from a cancerous focus in the 
uterus, tubes, and ovaries may give rise to many of the symptoms 
common to peritonitis. 

It is especially difficult to differentiate a carcinomatous peritonitis 
from a tuberculous peritonitis. The discovery of the primary lesion 
will suggest the diagnosis. 

Even after opening the abdominal cavity the diagnosis may be 
uncertain and require a microscopic examination of an excised por- 
tion. 

PELVIC PERITONITIS. 

Definition. Part or all of the pelvic peritoneum is involved in 
the inflammatory process. We therefore speak of diffuse and 
localized pelvic peritonitis. When localized various terms are em- 
ployed to designate the location and extent of the lesion. We speak 
of perimetritis when the peritoneal covering of the uterus is involved ; 
of perisalpingitis and periovaritis when involving the peritoneal 
coverings of the tube and ovary. 



396 



SPECIAL DIAGNOSIS. 



Of greater clinical importance is the distinction between a general 
abdominal and pelvic peritonitis and a well-defined pelvic peri- 
tonitis. A pelvic peritonitis may be primary or secondary to a 
general abdominal peritonitis — a fact of prime importance in its 
bearing upon the diagnosis and treatment. 

The infection is usually conveyed through the uterus and tubes 
to the peritoneum immediately surrounding these organs. A direct 
invasion from the uterus, tubes, rectum, appendix vermiformis, or 
bladder occurs with less frequency. 



Fig. 181. 




1 M. Levator ani.' 

Three divisions of the pelvic cavity, viz., peritoneal, subperitoneal, and subcutaneous. 

(Fehling.) 

It is possible for infection to be conveyed along the mucosa of the 
uterus and tubes to the peritoneum without causing anatomical 
changes in the uterus and tube«, or such changes may be limited to 
portions of the mucosa. 

Likewise, the lymphatic channels may be mere carriers of infec- 
tion without themselves being involved. We are, therefore, not 
justified in concluding that infection has not passed by a given route 
because there are no anatomical evidences of such an event. 



THE DIAGNOSIS OF PERITONITIS. 397 

Etiology. All that has been said of the etiology of endometritis 
will apply to pelvic peritonitis, inasmuch as the infection very often 
primarily attacks the endometrium. Pelvic peritonitis has its 
starting-point less frequently in an infection of the bowel, bladder, 
vagina, or general peritoneum. Traumatisms of the perineum, cer- 
vix, and vagina incident to parturition and surgical operations may 
open the way for infection, which is conveyed by the bloodvessels 
and lymphatics to the peritoneum. The micro-organisms chiefly 
found in the infected peritoneum are those common to endometritis, 
salpingitis, and ovaritis — that is, the staphylococcus pyogenes albus, 
aureus, and citreus, streptococcus pyogenes, gonococcus, colon bacil- 
lus, tubercle bacillus, Klebs-Loeffler bacillus, pneumococcus, typhoid 
bacillus, and actinomycosis. 

We speak clinically of acute and chronic pelvic peritonitis, of 
peritonitic exudates and adhesions. 

1. Acute pelvic peritonitis shows a marked congestion of the 
bloodvessels or a diffuse blush of the peritoneal surface. Clinically, 
this stage is recognized by intense pain and tenderness in the pelvis, 
contraction of the abdominal muscles, tympany, vesical and rectal 
tenesmus, and painful menstruation. The temperature is elevated ; 
the pulse is accelerated in proportion to the degree of temperature 
and general intoxication. Vomiting and hiccoughing are often 
present in advanced cases, and the patient lies with both legs flexed 
upon the thighs. 

In the acute stage all examinations and manipulations should be 
restricted as far as possible. It must be borne in mind that acute 
exacerbations of chronic peritonitis will give all the clinical evi- 
dences of a primary acute attack. Upon opening the abdomen, 
however, evidences will be found of previous involvement. Bandl 
says that high fever, great tenderness, and tympany in the pelvic 
regions are sure signs of pelvic peritonitis. It is only after the 
acute stage has subsided that a bimanual examination will make 
sure that the pelvic connective tissue is not diseased and that the 
peritoneum alone is affected. As a rule, the early symptoms must 
be relied upon in making the diagnosis, for in the majority of cases 
no palpable exudations take place. 

2. Chronic pelvic peritonitis usually begins as an acute infection, 
but may be chronic from the beginning. Bandl says : " The lesion 
can be diagnosed in girls and sterile women when, during the men- 
strual period or at any other time, with or without fever, there 



398 SPECIAL DIAGNOSIS. 

exist deep-seated pain in the pelvis and more or less tenderness 
over the lower portion of the abdomen. If the symptoms are con- 
fined to one side, as is usually the case, the process is most probably 
present in the form of a perisalpingitis and perioophoritis." In the 
opinion of the author, it is not possible to arrive at any intelligent 
conclusion from the above data as to the existence of chronic pelvic 
peritonitis. Too often mistakes are made by relying upon the com- 
plaints of nervous and ignorant patients. A physical examination 
will alone serve to differentiate the many possible causes of such 
complaints as are found in the inflammatory involvements, the dis- 
placements, and the new formations of the uterus and adnexse. 
The anatomical evidences of chronic pelvic peritonitis are inflam- 
matory exudates and adhesions. 

Peritoneal exudates follow closely upon the initial acute stage. 
The exudate is serous, seropurulent, or purulent, and may be found 
to occupy part or all of the pelvic cavity. The most dependent 
portion of the peritoneal cavity is the cul-de-sac of Douglas, and 
into it the peritoneal exudate naturally gravitates. It is possible 
for such an exudate to cause a bulging of the posterior vaginal 
fornix, though this is not the rule unless the underlying cellular 
tissue is involved. In a vaginal examination an exudate in the 
pouch of Douglas is sharply outlined, rounded below, and flat on the 
top. When too abundant to be wholly contained within the cul- 
de-sac, the exudate spreads out upon the posterior surface of the 
uterus, may extend laterally, and has been known to fill the 
entire inlet of the pelvis. The adherent and oftentimes distended 
intestine gives an indefinite outline to the upper border of the 
exudate. 

The consistency of the exudate is variable. Fluctuation may be 
marked, or the exudate may appear firm by virtue of the surround- 
ing inflammatory infiltration. 

In exceptional cases the exudate is located at the side or in front 
of the uterus. It is difficult to palpate it through the vagina be- 
cause of the high location. Without anaesthesia there is an indefi- 
nite sense of resistance at the seat of the exudate. Under anaes- 
thesia the inflammatory mass may be fairly outlined. Where a 
fluid exudate is encapsulated by adhesions, " adhesion cysts," it is 
possible to mistake it for a sactosalpinx or an ovarian cyst. 

Peritoneal adhesions may follow a serous or purulent exudate, or 
may develop independent of a fluid exudate. The adhesions may 



THE DIAGNOSIS OF PERITONITIS. 



399 



involve any part or all of the pelvic peritoneum. They manifest 
great variations in development, from a delicate fibrillar structure 
to dense bands. They are most frequently found about the adnexse 
and behind the uterus. Much less frequently are they found in 
front of the uterus, for the reason that the infection commonly 
travels through the tubes to the peritoneum, and it is unusual for 
the tubes to lie in front of the uterus. 



Fig. 182. 




Peritoneal adhesions bind, the uterus in retroposition. 



Gonorrhoea is the most common cause of adhesions, and next in 
point of frequency are the infections following labor and abortion. 
As a result of the adhesions the uterus and adnexse are more or less 
fixed, and their position is altered by contraction of the adhesions. 
With the exception of prolapsus and inversion of the uterus, all 
sorts of malpositions are caused by adhesions about the uterus and 
its appendages. 

The clinical diagnosis rests upon the physical findings. In a con- 
joined examination the adhesions are recognized as cords and bands, 



400 SPECIAL DIAGNOSIS. 

rarely as a diffuse thickening surrounding the viscera of the pelvis 
and uniting their peritoneal surfaces. 

The abnormal fixity of the organs and their displacement are 
suggestive of the presence of adhesions. Not infrequently such 
fixity and displacements are recognized in an examination without 
anaesthesia, and it is presumed that adhesions exist, though they are 
not demonstrated without the administration of an anaesthetic. 

Where displacements of the uterus and adnexce with restricted range 
of motion are associated with tenderness and an indefinite sense of 
resistance at the side of or behind the uterus, an anesthetic should 
be administered to determine the possible presence of adhesions and 
exudates. 

Differential Diagnosis. It is at times extremely difficult to 
differentiate a pelvic peritonitis from a hyperesthesia peritonii found 
in women of nervous temperament. The general nervous state of 
the individual, the absence of all causes of infection, and, finally, a 
conjoined examination under anaesthesia will serve to establish the 
diagnosis. 

A retroflexed gravid uterus may be confounded with a peritonitic 
exudate. The fact of pregnancy should be determined by the usual 
signs. In the first trimester the cessation of menstruation and 
nausea is occasionally simulated by like complaints due to the 
inflammatory lesion about the uterus in the absence of pregnancy. 
Such exudates are most often found in multipara? in whom the 
changes in the breast are not usually well-marked during the early 
months of pregnancy. Of greatest importance are the changes in 
size, form, consistency, and the rate of growth of the uterus. An 
effort to replace the uterus without anaesthesia, or, if this fails, with 
anaesthesia, will determine the presence or absence of adhesions. 

In exceptional cases a uterus fixed by adhesions cannot be distin- 
guished from an incarcerated uterus without an exploratory incision. 
This is particularly true where adhesions bind the uterus loosely to 
such movable structures as the bowel, omentum, and bladder. 

Where the uterus is fixed and tender to pressure adhesions are 
suspected, even though they cannot be felt under anaesthesia. 

A retro-uterine hsematocele may organize into peritoneal adhesions 
in the absence of infection. The history and physical evidence of 
an ectopic pregnancy, together with the usual signs of a haematoma 
and the absence of a history of infection, will serve to differentiate 
this condition from true inflammatory peritonitic adhesions. 



THE DIAGNOSIS OF PERITONITIS. 401 

Tuberculous peritonitis with encysted fluid, according to H. Dure, 
is differentiated from an ovarian cyst by a family history of tuber- 
culosis, signs of the existence of other tuberculous lesions, a history 
of frequent abortions or of the death of several children from tuber- 
culosis ; general symptoms of tuberculosis, such as loss of weight, 
strength, and appetite, evening rise of temperature, night sweats, 
pelvic pains, amenorrhoea, leucorrhoea, and the previous occurrence 
of salpingo-oophoritis. 

The differential diagnosis of pelvic inflammatory exudates from 
sactosalpinx and ovarian cysts is referred to in the chapters on 
Diseases of the Tubes and Ovaries. 



26 



CHAPTER XXXI. 

THE DIAGNOSIS OF PARAMETRITIS (PELVIC CELLULITIS). 

The loose connective tissue of the pelvis lies immediately beneath 
the peritoneum. It surrounds the supravaginal portion of the cer- 
vix, and extends laterally between the layers of the broad ligament 
and along the sides of the pelvis. There is but a small amount of 
connective tissue in front of the uterus beneath the vesico-uterine 
fold of peritoneum. Behind the uterus and beneath the uterorectal 
fold of peritoneum is a considerable amount of loose connective 
tissue so intimately connected with the rectum, cervix, and vagina 
that it frequently becomes the seat of infection. 

A knowledge of the location, loose texture, and relation of the 
connective tissue to the neighboring structures will serve as a basis 
for our understanding of pelvic cellulitis. 

Definition. By parametritis is meant an inflammation of the 
cellular tissue of the pelvis. The extent of the lesion varies. 
While sometimes diffuse, it is usually localized. According to the 
location of the lesion we recognize paracystitis, when the limited 
amount of connective tissue about the base of the bladder is in- 
volved ; paraproctitis, when the inflammation is in the cellular 
tissue about the rectum ; paravaginitis, when it is about the vagina; 
posterior parametritis, when in the connective tissue lying within 
the uterosacral folds and beneath the floor of the pouch of Douglas, 
and lateral parametritis, when between the layers of the broad liga- 
ment. 

Classification. Freund classifies parametritis as follows : 

I. Acute Inflammation of the Pelvic Connective Tissue 
with or without Abscess Formation. 

a. Simple phlegmon. 

b. Septic phlegmon. 

II. Chronic Inflammation of the Pelvic Connective 
Tissue. 

a. Circumscribed atrophic. 

b. Diffuse atrophic. 



THE DIAGNOSIS OF PARAMETRITIS. 



403 



The causes of pelvic cellulitis are identical with those of pelvic 
peritonitis, and it is the rale that these lesions rarely exist singly. 

I. Acute Parametritis. The initial symptoms are, as a rule, less 
violent than in acute pelvic peritonitis. This is particularly true 
of the pain and tenderness. The effect upon the pulse and tem- 
perature may be equally severe. 



Fig. 183. 




Parametritis. Exudate in left subperitoneal cavity, crowding corpus uteri to right. Para- 
colpitis in right subcutaneous cavity, crowding cervix uteri and vagina to left. This latter 
would produce a perianal abscess, and would usually be followed by fistula in ano. (Dudley.) 



Bandl says : " If a day or two after an attack of fever and the 
appearance of the described initial symptoms the uterus is found 
enlarged transversely in the region where the broad ligaments leave 
it, parametritis certainly exists, and it is hardly necessary to prove 
it by bimanual examination. If after fever has lasted for several 
days points of resistance are found over Poupart's ligament corre- 
sponding to the seat of pain and tenderness ; or if swellings have 
formed above or extend to the centre of Poupart's ligament, or 
internally to the anterior superior spine of the ilium, the convex 



404 SPECIAL DIAGNOSIS. 

border of which is readily felt or even seen ; or if by firm pressure 
of the abdominal wall tumors corresponding to the broad ligament 
are found, then it is also certain that the process involves the para- 
metrium. If still doubtful, the diagnosis may be confirmed by 
vaginal examination, which in most cases will reveal the presence 
of large masses at the sides of the uterus, extending anteriorly or 
laterally to the pelvic wall, or filling one side of the pelvic cavity, 
showing clearly that the swellings felt through the abdominal wall 
are masses of exudation extending below the peritoneum." 

In many cases the exudate cannot be felt through the abdominal 
wall, because it lies low in the pelvis and is only to be palpated 
through the vagina. " If with more or less inflammatory symptoms 
masses form in the neighborhood of the cervix, or extend to the 
deeper portions of the pelvis, being doughy and soft at the begin- 
ning but rapidly becoming harder, or if large, well-defined swellings 
form in the true pelvis, in front of or behind the uterus, the process 
can be none other than phlegmonous inflammation of the cellular 
tissue." 

II. Chronic parametritis is diagnosed from the position and con- 
sistency of the exudate and its relation to neighboring structures. 
The history of the infection, together with the general and local 
symptoms, can no more than suggest the probable nature of the 
lesion. 

Position of the Exudate. The exudate occupies the position of 
the pelvic connective tissue and with greatest frequency in localities 
where the connective tissue is most abundant, namely, behind the 
uterus and between the layers of the broad ligaments. In either 
case the exudate lies low in the pelvis. 

When involving the connective tissue at the base of the broad 
ligaments the exudate spreads to the sides of the pelvis. Behind 
the uterus it bulges down into the vagina, forming a rounded, tender 
swelling in the posterior cul-de-sac. When involving the connec- 
tive tissue at the sides of the pelvis, it spreads into a flat mass which 
may or may not connect with the uterus by an elongated exudate 
within the broad ligament. 

It is possible for the exudate to dissect in front and behind in 
the subperitoneal connective tissue of the abdominal wall. It is 
impossible for the exudate to burrow to a level above the umbilicus, 
because at this level the subperitoneal connective tissue disappears, 
nor can the dissection go beyond the median line. In this manner 



THE DIAGNOSIS OF PARAMETRITIS. 405 

an abscess may burrow, there being a greater tendency on the part 
of purulent collections to gravitate to a lower level than is the case 
with non-suppurative exudates. The abscess is finally discharged 
through the bladder, vagina, rectum, abdomen, or through one of 
the pelvic foramina. 

The form of the exudate varies according to its consistency and 
location. The exudate moulds itself to neighboring structures. 
Beneath the cul-de-sac of Douglas it is somewhat rounded because 
of the limited resistance offered by the surrounding soft structures. 
Between the resisting layers of the broad ligaments the exudate is 
flattened, and the same is true to a greater degree at the sides of 
the pelvis. As the exudate is absorbed its form changes, because 
this removal proceeds irregularly. 

Mobility in the exudate is scarcely perceptible. If attached by 
a broad base to an immovable structure the exudate will be firmly 
fixed. A small exudate within the broad ligament may show some 
degree of mobility, but as a rule we speak of cellular exudates as 
fixed and immovable. 

The consistency is also subject to great variations, depending upon 
the character of the exudate, whether oedematous, fibrinous, or 
purulent. At one time it is soft and fluctuating, and again it is as 
firm as cartilage. In the early development of the exudate the con- 
sistency is elastic and yielding ; later it becomes firm from organiza- 
tion and contraction. If suppuration ensues there will be a boggy 
and possibly fluctuating mass. The consistency is best determined 
by rectal and vaginal palpation. 

Tenderness to pressure is characteristic of all inflammatory lesions. 
Large exudates may exist with very little tenderness, but usually 
the tenderness is a reliable guide to the inflammatory character of 
the mass. 

The relation of the exudate to neighboring organs is most impor- 
tant in the consideration in differentiating from new formations in 
the pelvis. The exudate blends intimately with adjacent structures 
and cannot be outlined apart from them. 

In intraligamentous exudates the mass lies snugly against the side 
of the uterus, sometimes surrounding the supravaginal portion of 
the cervix, but never extending to the fundus. In paravaginitis it 
may be impossible to move the vaginal mucosa from the exudate. In 
paraproctitis the exudate may bulge into the rectum, narrowing the 
bowel and so intimately blend with the wall of the rectum that it 



406 



SPECIAL DIAGNOSIS. 



moves as one mass. In the absorption of the exudate the periphery 
is first to disappear. In an intraligamentous exudate the mass may 
retreat from the side of the pelvis and form an elongated or rounded 
swelling firmly adherent to the uterus. 

Differential Diagnosis. The distinction between a perimetric 
and a parametric exudate is at all times difficult. Certain well- 
defined points of distinction serve to differentiate the two lesions, 
but it is to be remembered that they commonly coexist. 



Parametritis. 
Exudate lies low in the pelvis. 
Pain may not be great, and is dull and 

continuous. 
Exudate commonly at the side of the 

uterus, never extending to the fundus. 
Exudate of firm consistency ; tendency to 

suppuration. 
Uterus partially fixed. 
Tympanitis usually absent. 
Facial expression may be natural. 
Nausea and vomiting not common. 
One leg flexed. 



Pelvic Peritonitis. 

1. Lies high in the pelvis. 

2. Pain usually more intense, sharp, lanci- 

nating, and paroxysmal. 

3. Exudate commonly behind the uterus, 

often extending to the fundus. 

4. Commonly less firm ; no great tendency to 

suppurate. 

5. Uterus may be firmly fixed. 

6. Tympanitis usually present. 

7. Facial expression anxious. 

8. Nausea and vomiting common. 

9. Both legs flexed. 



Retro-uterine Parametritis. 

1. Outline rounded below and sharply cir- 

cumscribed. 

2. Exudate cannot extend to fundus. 

3. Uterus may be crowded forward ; usually 

only the cervix is crowded forward. 

4. Rectum firmly and closely surrounded by 

exudate in front and at the side. 

5. Mucosa of rectum does not move upon the 

exudate. 

6. Posterior vaginal fornix depressed. 



Retro-uterine Perimetritis. 

1. Outline diffuse, not sharply circumscribed. 

2. Exudate may extend above fundus. 

3. Uterus may be crowded forward by the 

exudate or drawn backward by adhesions. 

4. Rectum crowded backward by exudate. 

5. Mucosa moves independently of the mass. 

6. Usually not depressed. 



A paratyphlitic exudate is not infrequently confounded with an 
intraligamentous parametritis. It is possible for a paratyphlitic 
exudate to burrow between the layers of the broad ligament to the 
side of the uterus. 



Perityphlitis. 

Initial symptoms: nausea, vomiting, con- 
stipation, fever, pain at McBurney's 
point. 

Tendency of a parametric abscess is to 
rupture into the bowel and peritoneal 
cavity. 

Tendency to recurrence. 

Exudate lies high on the right side and 
spreads from above downwRrd. 



Parametritis. 

1. Initial symptoms : fever, constipation, pain 

low in the pelvis at the side of the uterus, 
rarely nausea and vomiting. 

2. Little tendency to rupture into the bowel 

and peritoneal cavity. 

3. Tendency to recurrence not so great. 

i. Exudate lies low in the pelvis and spreads 
from below upward. 



A pelvic haematoma may so closely resemble a parametric exudate 
as to be indistinguishable without an exploratory incision or punc- 



THE DIAGNOSIS OF PARAMETRITIS. 



407 



ture. Both lesioiis are confined to the cellular tissue of the pelvis 
and in general contour, size, and consistency they may be quite 
similar. The following tabulated points will usually serve to 
differentiate the two : 



Pelvic Hjematoma. 

1. Develops suddenly. 

2. History of ectopic pregnancy. 

3. Onset marked by normal or subnormal 

temperature and rapid, feeble pulse. 

4. Exudate usually beside the uterus and cir- 

cumscribed. 

5. Exudate at first doughy, later firm, never 

tender unless infected. 

6. Exploratory puncture, blood. 



Parametritis. 

1. Develops more gradually. 

2. Absent. 

3. Onset marked by rise of temperature and 

increased pulse rate. 

4. Exudate beside or behind the uterus and 

less circumscribed. 

5. Exudate firmer and tender. 



Exploratory puncture, serum, pus, or nega- 
tive. 



Subserous fibroids may be confounded with a parametric exudate. 
When the exudate is round and attached by a broad base to the 
uterus and not especially tender on pressure, the diagnosis is diffi- 
cult and may not be cleared up without an exploratory incision. 
The difficulty of diagnosis is especially great in intraligamentous 
fibroids. The more movable the mass the more likely it is to be a 
fibroid. In a cellular exudate there is a history of infection and 
the mass grows rapidly. In fibroids there is no history of infection 
and the growth develops slowly. The depth of the uterine cavity 
is increased in case of fibroids beyond that found in parametritis. 
The effects of treatment will aid in the diagnosis ; in parametritis 
the mass should diminish under treatment, while in fibroids little 
or no effect will be observed. 

Malignant diseases of the pelvis, involving the parametrium, may 
arise from a primary focus in any of the pelvic viscera. There is 
absence of a history of infection, no acute onset being experienced, 
and there are present the general symptoms of malignancy rather 
than of infection. The primary seat of malignancy can usually be 
determined, and the hard, irregular character of the infiltrated area 
will serve to indicate the condition. 



Parametritis. 

1. Usually of acute origin. 

2. Absence of spondylitis. 

3. Exudate tender to pressure. 

4. Fluctuation may be absent ; induration 

about abscess always present. 

5. Thigh flexed, not rotated. 

6. Temperature may be high. 

7. Exploratory puncture shows absence of 

tuberculous exudate and tubercle bacilli. 

8. Tuberculin gives no reaction. 



Psoas Abscess. 

1. Usually of chronic origin. 

2. Spondylitis present. 

3. Exudate not tender to pressure. 

4. Fluctuation only occasional ; no hard exu- 

date about abscess. 

5. Thigh flexed and rotated inward. 

6. Temperature absent or slight rise, espe- 

cially in the morning. 

7. Presence of same. 

8. Tuberculin usually gives a reaction. 



PAET III. 

THE DIAGNOSIS OF THE DISEASES OF 
THE URINARY SYSTEM. 



CHAPTER XXXII. 

THE DIAGNOSIS OF THE DISEASES OF THE UEETHEA 
AND BLADDER. 

AVixckel, in his monograph on " Diseases of the Female 
Urethra and Bladder," has pointed out that much that is now 
known of the diseases of the urethra and bladder was known hun- 
dreds and thousands of years ago, and, having been forgotten, was 
rediscovered by late observers. The Cnidian school possessed a 
fairly accurate knowledge of diseases of the bladder, as did the 
Indians 100 B.C. JEtius (502-575 B.C.) described ulcerative affec- 
tions of the bladder, and Paul of JEgina (670 a.d.) treated diseases 
of the bladder by means of injections through a catheter. In the 
nineteenth century Simon devised a series of conical specula with 
obturators, by which the urethra could be dilated to the extreme 
degree, permitting a digital examination of the bladder. From that 
time to the present methods of examining the urinary tract have 
been rapidly introduced and perfected. "We are especially indebted 
to Max Nitze, K. Pawlik, M. Sanger, and Howard Kelly, whose 
contributions to this department of the diseases of women rank with 
the most important of the past century. 

Anatomy and Physiology of the Urethra and Bladder. 
Urethra. The average length of the female urethra is one to one 
and a half inches. It runs from below upward and backward in a 
straight or slightly curved line, and its anterior extremity lies about 
four-tenths of an inch below the symphysis. 

The wall of the urethra is about one-fifth of an inch thick, and 
possesses an unusual amount of elastic fibre, which permits a great 



410 DIAGNOSIS OF DISEASES OF THE URINARY SYSTEM. 

degree of stretching. The epithelium in the lower segment of the 
urethra resembles the stratified epithelium of the vagina, while that 
of the upper segment is like that of the bladder. 

Near the external urethral orifice Skene found two lacunse which 
he regarded as glands. They are known as Skene's ducts. Their 
orifices, which open into the urethral canal, are about one-twentieth 
of an inch in diameter. The ducts are about one-quarter of an 
inch long and run upward along the wall of the urethra. A fine 
probe can be inserted into them for about one inch. 

Numerous smaller lacunse lie along the course of the urethra. 
These are lined with transitional epithelium, the lowermost being 
a single layer of cylindrical epithelium. Higher up it becomes 
stratified cylindrical, and near their mouth it becomes flat pavement. 
In addition to these lacunar there are numerous small mucous glands 
opening into the canal. Beneath the mucosa is the submucosa com- 
posed of an elastic network, and external to this is the muscular 
wall composed of longitudinal and circular muscular fibres. 

The external orifice of the urethra is a vertical oval opening 
one-fifth of an inch long, while the internal orifice is a mere slit. 

Bladder. The empty female bladder lies in the median line 
behind the pubis and in front of the vagina. When the fundus is 
distended it inclines slightly to the right side and may reach to the 
level of the umbilicus. The average capacity is 400 grammes, 
which is somewhat less than that of the male bladder. The 
minimum capacity is 20 to 30 grammes, and the maximum 3320 
grammes (Fritsch). The bladder wall consists of three layers — 
peritoneal, muscular, and mucous. 

1. The peritoneum covers the fundus of the bladder and is 
reflected to the anterior surface of the body of the uterus and to the 
anterior abdominal wall. It is loosely adherent to the muscularis. 
When the bladder is greatly distended the peritoneum is so drawn 
upward that a hand's breadth of the bladder not covered with peri- 
toneum presents above the pubis — a fact to be remembered in 
suprapubic operations on the bladder. 

2. The middle layer consists of unstriped muscular fibres 
arranged in three sublayers, namely, an external layer of longi- 
tudinal fibres, a middle layer of oblique and transverse fibres, and 
an internal layer of longitudinal fibres. 

3. The internal layer — mucosa — is composed of several 
layers of transitional epithelium resting upon a loose connective 



DIAGNOSIS OF DISEASES OF URETHRA AND BLADDER, 411 

tissue base. Folds or rugae are found over the entire inner surface 
of the bladder, with the exception of the trigone and openings. 
These are due to laxity of the mucosa. In the trigone the mucosa 
closely adheres to the subrnucosa, and therefore no folds are to be 
seen. Small acinous glands which secrete mucus are distributed 
in the mucous membrane of the fundus and about the internal 
sphincter. 

The bladder is rich in bloodvessels. A thick, capillary network 
runs beneath the superficial epithelium of the mucous membrane. 
The vertex is not so richly supplied with bloodvessels as the deeper 
parts. The arteries supplying the bladder are the vesicularis 
superior and inferior branches of the arteria hypogastrica. The 
veins empty into the plexus pudenda vesicularis. 

The nerve supply comes from the plexicus hypogastricus inferior 
of the sympathetic system and from the third and fourth sacral 
nerves. 

The bladder has three openings : the internal orifice of the 
urethra and the two orifices of the ureters, which lie one and one- 
half inches above and to either side of the urethral opening. The 
ureteral openings are separated about one inch and are connected 
by a prominent fold of the mucous membrane known as the liga- 
mentum uretericum. The three openings form the angles of a 
triangle known as the trigone. Above the trigone on the posterior 
wall of the bladder is the bas fond, and all the bladder lying above 
the level of the ureteral openings is known as the body or fundus. 
That which will be spoken of as the sphincter vesicae probably 
consists of the folds of mucous membrane at the internal orifice of 
the urethra. 

Physiology of the Bladder. The ureters and bladder possess 
peristaltic movements by which the urine is forced through the 
ureters into the bladder and from the bladder past the sphincter 
internus. These systolic and diastolic movements of the bladder 
have an important clinical bearing in that rest cannot be given to 
the inflamed bladder without artificial drainage. The anterior wall 
of the empty bladder lies upon the posterior wall. When the urine 
enters the bladder it first gravitates to the side pockets and gradually 
elevates the anterior wall. Before the bladder is distended the walls 
are lax and flat ; after distention they become tense and rounded. 

Topography of the Bladder. By the present perfected methods 
of examination it is possible to bring into view and to directly 



412 DIAGNOSIS OF DISEASES OF THE URINARY SYSTEM. 

treat all lesions of any portion of the bladder ; hence the necessity 
of exact means of describing the location and extent of these lesions. 
The following scheme of divisions and subdivisions of the interior 
of the bladder is proposed by Howard Kelly : 

1. The natural landmarks within the bladder. 

2. The relation of the bladder to surrounding structures. 

3. An artificial division into hemispheres and quadrants. 

1, The Natural Landmarks in the Bladder, (a) The internal 
orifice OF the urethra marks the junction of the urethra and 
bladder. 

(6) The ureteral orifices are to be regarded as the most 
important of the landmarks of the bladder. The orifices lie at the 
top or to one side of the so-called ureteral prominences, which are 
truncate cones 5x3 mm. 

(c) Ureteral folds is a name given by Kelly to designate 
rounded elevations sometimes seen in the mucosa stretching back- 
ward and outward from each ureteral opening toward the pelvic 
walls and for a distance of about three-quarters of an inch. They 
are regarded by Kelly as the terminal ends of the ureters as they 
pass through the bladder walls. 

(e?) The trigone is a triangular area at the base of the bladder, 
having angles formed by the internal urethral and the two ureteral 
openings ; the sides connecting these openings bound the trigone 
and are about one inch long at the base and three-quarters of an 
inch long at either side. Many of the lesions of the bladder are 
confined to this area. 

(e) The interureteric ligament connects the ureteral emi- 
nences and is seen as a line sometimes elevated and separating the 
smooth, deeper colored surface of the trigone from the paler surface 
of the bladder. 

(/) Kelly calls attention to the important points relating to the 

FIXED AND MOVABLE PORTIONS OF THE BLADDER. As the bladder 

is emptied the upper and more movable portions settle down into 
the lower and more fixed portions like one saucer within an- 
other. He observes that the location of inflammatory lesions is 
determined somewhat by the movable and fixed areas. Viewing 
the interior of the bladder with a cystoscope, the respiratory 
movements define the movable area as contrasted with the fixed 
portion. 

The edges where the two saucers meet form three folds, a pos- 



DIAGNOSIS OF DISEASES OF URETHRA AND BLADDER. 413 

terior and two lateral folds. The apices formed by the meeting of 
these folds are known as the right and left vesical cornua. 

2. Relations of the Bladder to Surrounding Structures. The 
trigone lies in close proximity to the anterior vaginal wall. Above 
this the base of the bladder is in direct apposition to the supra- 
vaginal portion of the cervix. The upper half of the bladder is 
loosely covered with peritoneum. The above relations are impor- 
tant in operative procedures upon the bladder and surrounding 
structures. 

Fig. 184. 




Expression of pus from the ducts of Skene's glands. (Kelly 



3. Artificial Division of the Bladder into Hemispheres and Quad- 
rants. The distended bladder may be regarded as a sphere divided 
into right and left hemispheres. The intersection of sagittal and 
horizontal planes further divides the bladder into quadrants — the 
right upper and lower quadrants and the left upper and lower 
quadrants. 

Methods of Examining the Urethra and Bladder : 

1. Percussion. 

2. Palpation. 

3. Catheter and Sound. 

4. Inspection (specular). 

5. Urinalysis. 

1. By percussion a bladder distended with fluid may be outlined. 
The area of dulness may extend to the umbilicus. The more dis- 



414 DIAGNOSIS OF DISEASES OF THE URINARY SYSTEM. 

tended the bladder, the more conical the shape. A bladder dis- 
tended with air gives a high-pitched tympanitic note. 

2. By palpation many of the lesions of the urethra and bladder 
are detected. 

(a) The urethra is directly palpated along the median line of the 
anterior vaginal wall. In urethritis palpation will be painful in 
proportion to the intensity and extent of the inflammation ; the 
urethra may be felt" as a firm cord. 

Fig. 185. 




The thickened bladder is engaged between the index and middle finger of the right hand in 
the vagina, and the fingers of the left hand over the abdomen. 



Fissures and caruncles at the urethral orifice are exquisitely sen- 
sitive to pressure. 

By previously dilating the urethra with bougies it is possible to 
insert the finger through the urethra into the bladder for the pur- 
pose of detecting irregularities and foreign growths. 

(b) The bladder when empty is seldom recognized in a bimanual 
examination. In cystitis tenderness and pain are proportionate to 
the intensity and extent of the lesion. In chronic cystitis, and par- 
ticularly in tuberculous cystitis, the thickened bladder wall may be 



DIAGNOSIS OF DISEASES OF URETHRA AND BLADDER. 415 

distinctly palpated through the vagina. Stone may sometimes be 
palpated and outlined in an abdomino- vaginal examination. 

Kelly recommends placing the patient in the knee-chest position 
and letting the air distend the vagina, when the fingers of both 
hands can be brought close together and the entire bladder be 
distinctly outlined. 

While possible to palpate a portion of the interior of the bladder 
through the dilated urethra, such a procedure is no longer to be 
recommended in view of the more efficient and less objectionable 
method of direct inspection. 

3. By Catheter and Sound. By the use of the catheter the urine 
is evacuated from the bladder and can be examined free of con- 
taminations with products of the urethra and vagina. By the catheter 
foreign bodies, stricture, and fistula? are sometimes detected in the 
urethra and bladder. The sound is a more efficient instrument for 
the detection of such conditions. 

4. Inspection of the urethra and bladder has been made possible 
by the contributions of Nitze, Casper, Pawlik, Skene, Simon, 
Kelly, and others. In almost all diseases of the urethra 

and bladder it is desirable to make an exact diagnosis by 
direct inspection. 

The lesions involving the urethral orifice can be recog- 
nized by direct ocular inspection. Pus seen to ooze from 
the urethra is, with few exceptions, recognized as of gonor- 
rhoeal origin. The orifices of Skene can be directly in- 
spected by separating the lips with the fingers. By 
separating the labia and introducing a speculum direct 
inspection will disclose a vesicovaginal fistula, vesicocele, 
and tumors of the base of the bladder and urethra growing 
into the vagina. 

Urethroscopy. An endoscope is introduced the entire 
length of the urethra. Light is reflected by a head mir- Ur f hral 

° ° J calibrator. 

ror into the urethra as the instrument is withdrawn. 
The mucosa collapses about the end of the urethroscope, forming 
a flat funnel which can be directly inspected. By virtue of the 
compression the mucosa is unnaturally pale. Polyps, new-growths, 
foreign bodies, ulcers, and inflamed surfaces are thus brought into 
the field of vision and are made accessible to direct treatment. 

Cystoscopy. Two methods of inspecting the interior of the 
bladder will be described — the Kelly- Pawlik and the Nitze. There 



416 DIAGNOSIS OF DISEASES OF THE URINARY SYSTE3I. 

are numerous modifications of these methods, all worthy of con- 
sideration were there space to devote to them. 



Fig. 187. 



Fig. 188. 





Fig. 187.— Nitze's ureter cystoscope for illuminating the bladder and simultaneous catheteri- 
zation of the ureters. 

Fig. 188.— Janet-Frank's bladder phantom. Intended for practising cystoscopy, ureteral 
catheterization, and intravesical operations. 



DIAGNOSIS OF DISEASES OF URETHRA AND BLADDER. All 

The Nitze cystoscope is not in general use in the United States, 
preference being given to the direct method of Kelly and Pawlik. 
On the Continent the Nitze and various modifications, such as 
Casper's, are quite generally used. Each has its merit, and is 
deserving of full consideration. 

The following are the advantages of the Nitze cystoscope as com- 
pared with the Kelly-Pawlik : 

1. A general anaesthetic is seldom required. 

2. The lithotomy position is used to the best advantage. 

3. The bladder is more completely dilated with water than with 
air. 

4. The urethra is not widely dilated, hence incontinence of urine 
seldom occurs. 

5. No assistance is required in making the examination. 

6. Less skill and a shorter time is required in making the exam- 
ination. 

Technic. Four conditions are prerequisite to the use of the Nitze 
cystoscope : 

1. Permeability of the urethra, sufficient to easily permit the 
passage of the cystoscope. This requires a diameter of not less 
than 5 mm. 

2. A capacity sufficient to retain at least 100 c.c. of fluid. 

3. Power on the part of the sphincter vesicas to retain the fluid. 

4. Transparent fluid. 

1. Permeability. It is essential that the cystoscope should pass 
into the bladder without meeting unusual resistance. Otherwise 
the pressure on the mucus glands may smear the lamp with mucous 
secretion and thereby obscure the field of vision. Where an 
obstruction exists in the urethra it must be removed before the 
cystoscope is introduced. Strictures and foreign growths of the 
urethra are uncommon in women. Spasmodic contractions of the 
sphincter vesicae may obstruct the passage of the cystoscope, but this 
may be overcome by slow, continuous pressure and by an anaes- 
thetic. 

2. Capacity of the Bladder. The usual amount of fluid injected 
into the bladder preparatory to making a cystoscopic examination 
is 250 c.c. A capacity of less than 100 c.c. precludes the examina- 
tion, because of imperfect distention of the bladder and the danger 
of overheating the mucous membrane. If irritability of the urethra 
and bladder does not permit the retention of a sufficient amount of 

27 



418 DIAGNOSIS OF DISEASES OF THE URINARY SYSTEM. 

fluid with which to distend the bladder, it may be possible to 
overcome the irritability by the application of a 2 per cent, solution 
of cocaine to the sphincter vesicae. Injection of the solution into 
the bladder is not regarded as a safe procedure. Where this will 
not overcome the irritability, rest must be enjoined until it has sub- 
sided. In the absence of cystitis the irritability readily reacts to 
the influence of cocaine applied to the urethra. 

Several fatal cases of cocaine poisoning have resulted from injec- 
tion of the solution into the bladder. 

If the indication for a cystoscopic examination is urgent in the 
presence of an irritable bladder and urethra, a general anaesthetic 
may be given. 

The female bladder will not distend so evenly as will the male 
bladder, because of the union of the posterior wall with the cervix 
and vagina, and because of the encroachment of the uterus, adhesions, 
pelvic tumors, and other swellings upon the bladder. 

3. Integrity of the Sphincter Vesiccv. If for any reason the 
bladder will not retain the urine, the Nitze cystoscope should be 
discarded in favor of the Kelly-Pawlik. 

4. Transparent Medium. The injected fluid must be sterile, non- 
irritating, and transparent. A normal salt solution, sterile water, 
or, preferably, a saturated solution of boric acid may be used. 
Carbolic acid, bichloride solution, and formalin are too irritating, 
causing an unnatural congestion of the mucosa. 

The lithotomy position is preferred, the patient lying on a high 
table. The urethral opening is cleansed as for the passing of a 
catheter. The urine is then withdrawn through a soft-rubber or 
glass catheter, and without withdrawing the catheter the bladder 
is irrigated with a boric acid or normal salt solution. A fountain 
syringe may be employed, but a piston syringe holding 250 c.c. is 
better. When the injected fluid is returned clear, about 250 c.c. of 
the fluid is left in the bladder preparatory to the introduction of the 
cystoscope. As a rule, the fluid returns clear after two or three 
injections. Where there exists a sediment of mucus, blood, or pus 
several injections may be required, and there are cases in which it 
is impossible to bring about perfect clarity. In such cases the con- 
tained fluid is being continually contaminated by blood and pus 
from the kidneys and ureters. When this is the case it is best to 
slowly inject a small amount of the fluid and to repeat the injection 
before all of the fluid is returned. By taking this precaution the 



DIAGNOSIS OF DISEASES OF URETHRA AND BLADDER. 419 

sediment at the bottom of the bladder will not be disturbed. It 
sometimes occurs that rnucus, pus, and concretions so cling to the 
wall of the bladder that it is impossible to carry out a cystoscopic 
examination. The fluid may appear cloudy because the lamp is 
smeared with mucus in its passage through the urethra. In such 
an event the instrument must be withdrawn and cleansed. 

CYSTOSCOPIC APPEARANCE OF THE NORMAL BLADDER. 

With the bladder moderately distended the surface of the mucous 
membrane is smooth. Circumscribed nodular swellings appear late 
in life and are caused by the intersection of muscular bands — the 
so-called trabecular which traverse the wall in all directions. Such 
nodular elevations are not to be mistaken for tubercular nodules. 
Between the trabecular, which cross one another at all angles, are 
irregularly shaped depressions. These are the forerunners of the 
pathological condition known as diverticula and hernia. 

The color of the mucosa varies within wide limits. In the 
normal state this variation in color is found not only in different 
bladders, but in various portions of the same bladder. By reflected 
artificial light the normal color is gray or yellowish-rose. The 
variations in color presented at different points in the bladder are 
accounted for by the relative position of the prism to the field of 
vision. For this reason the shades of color change with the move- 
ments of the prism. The nearer the prism approaches the surface, 
the brighter the color. As the heat of the lamp warms the con- 
tained fluid, the mucosa shows a hypersetnic reaction. 

The bloodvessels appear as a fine network of veins and arteries ; 
the base of the bladder is more vascular than are other portions. 
With the exception of the field near the sphincter vesicae, the veins 
are rarely seen in the normal bladder. 

From a clinical point of view the most important parts of the 
bladder are the trigone and base. It is here that foreign bodies and 
pathological lesions are most often observed. The trigone presents 
a smooth, glistening surface, varying in color from gray to dark red, 
and contains a close network of capillaries. 

As the cystoscope is slowly introduced the first image to greet 
the eye is that of the sphincter vesicce, which appears in the upper 
or lower segment of the field of vision, depending upon the respec- 
tive direction of the cystoscope ; the image above is the lower 



420 DIAGNOSIS OF DISEASES OF THE URINARY SYSTEM. 

segment of the sphincter, and vice versa. Pushing the instrument 
forward the image is slowly lost to view. At the base of the 
bladder the ligamentum uretericum is seen as a ridge of more or less 
prominence, running transversely for a distance of about one inch. 
Turning the instrument slightly to the right or left the ureteral 
prominence is seen at the end of the ureteric ligament. The prom- 
inence varies in size, form, and color. This is often true of the 
two prominences in the same bladder. The image increases in 
size and transparency as the prism is moved toward the object, 
decreasing in size and becoming darker as the prism is withdrawn. 
It is important to look for small vessels radiating from the ureteral 
prominence, for at the point from which the vessels radiate the 
ureteral opening is found. It is often possible to see the ureteral 
openings in the centre or at one side of the prominence. 

Difficulty in finding the ureteral opening is experienced when, as 
occasionally happens, the prominence is wanting. When one ureteral 
opening is found, the other is to be sought for at a corresponding 
point at the opposite extremity of the ureteric ligament. Slight 
variations in position are sometimes observed. One or both ureteral 
openings may be found close behind the sphincter vesicae, or they 
may lie some distance beyond the boundaries of the trigone. When 
it is seemingly impossible to discover the position of the ureteral 
openings, it is well to quietly and patiently look for the ripple of 
the urine as it is discharged into the bladder from the ureters. 
When the ureteral openings are hidden from view by folds of 
mucous membrane, a greater quantity of fluid may smooth out the 
folds and present the ureteral openings to view. 

Air-bubbles are usually present. It is impossible to avoid intro- 
ducing them, but happily they are no embarrassment in the exam- 
ination. They are round, oval, or hour-glass in form, and move 
together with the contained fluid. 

Movements of the bladder are seen, and are ascribed to the respira- 
tory excursions and to the movements of neighboring structures. 

Salt deposits of a red or grayish-white color are found on the 
surface of the bladder under perfectly normal conditions. They 
are distinguished from pus and tubercles by their color, their sharp 
margins, and by the fact that they are a deposit upon and not an 
infiltration of the mucosa. 

Small cystic elevations, the size of a pinhead, may extend over the 
entire surface of the bladder. They are particularly noticeable 



DIAGXOSIS OF DISEASES OF URETHRA AXD BLADDER. 421 

near the sphincter vesica?. Xo pathological significance is to be 
attached to them. 

The Kelly-Pawlik method, when efficiently carried out, is the 
most satisfactory of all methods of cystoscopy. The fundamental 
principles of a cystoscopic examination as given by Kelly are : 

1. The introduction of a simple cylindrical speculum into the 
bladder. 

2. The atmospheric distention of the bladder, induced slowly by 
posture. 

3. The illumination and inspection of the vesical mucosa, either by 
means of a direct light, such as a little electric lamp attached to the 
examiner's forehead or to the mouth of the speculum, or by means 
of a strong light reflected by a head mirror. 

The Techxic of the Examination. The field of operation, 
the instruments used, and the hands of the operator are to be 
sterilized as for an operation. The bladder and bowel should be 
emptied immediately before the examination. 

Fig. 189. 




Glass tube, with rubber catheter. 

On account of nervousness on the part of the patient or unusual 
irritability of the urethra, chloroform anaesthesia may be chosen if 
not contraindicated. In the majority of cases no anaesthetic is 
required. Kelly recommends the application of a 10 per cent, 
cocaine solution to the urethra just within the external orifice. 
The application is made on a pledget of cotton wound on a metal 
rod. By this means the urethra can be dilated to the required 
degree without great suffering. 

The Posture of the Patient. Kelly recommends the elevated 
dorsal and the knee-chest positions. "While the elevated dorsal 
position is the most convenient and least fatiguiug to the patient, 
it is not so efficient, because the bladder does not distend so perfectly 
as in the knee-chest position. 



422 DIAGNOSIS OF DISEASES OF THE URINARY SYSTEM. 

In the elevated dorsal position the hips are elevated from the 
table eight to twelve inches by firm pillows. The head and thorax 
rest on the table. As a preliminary measure to secure perfect dis- 

FiG. 190. 




Urethral dilator. 



tention of the bladder, the patient may assume the knee-chest posi- 
tion and a catheter be introduced into the bladder, through which 



Fig. 191. 




Glass graduate, with rubber tube and bulb. 



the air may enter. In a minute or two the patient may resume 
the elevated dorsal position, taking care that the hips are constantly 
held at a higher level than the abdomen. By so doing the weight 



DIAGNOSIS OF DISEASES OF URETHRA AND BLADDER. 423 



of the small intestines is taken from the bladder and when the 
urethra is dilated the bladder will be perfectly distended. 



Fig. 192. 



w. R. Grady Co. 



Fig. 193. 



Ureteral searcher. 
Fig. 194. 




Fig. 195. 





i 



Fig. 193.— Ureteral catheter, with handle sufficiently reduced to allow speculum to be with- 
drawn after catheter is engaged in ureteral orifice. 
Fig. 194.— Delicate mouse-toothed forceps. 
Fig. 195.— Vesical curette. (Kelly.) 



424 DIAGNOSIS OF DISEASES OF THE URINARY SYSTEM. 

The knee-chest position is preferred by Kelly, who regards it as 
applicable to all cases. When the patient can endure the exertion 
no anaesthetic need be given. The patient kneels close to the edge 



Fig. 196. 




Evacuator used lor withdrawing residual urine. 
Fig. 197. 




Ureteral catheters, with rubber tube. 



DIAGNOSIS OF DISEASES OF URETHRA AND BLADDER, 425 

of_a firm table. The hips are kept at the greatest elevation, while 
the breast and side of the face lie flat upon the table. The small 
of the back curves inward. The knees are separated about twelve 
inches. Where an anaesthetic is required the body may be sup- 
ported by an apparatus shown in Fig. 199, or by an assistant at 
either side. 

Of immense advantage over the dorsal and knee-chest positions 
is the elevated lithotomy position as advocated by Webster in 

Fig. 199. 




Dorsal position. Elevated pelvis. (Kelly.) 



the Journal of the American Medical Association, May 17, 1902. 
During the past three years Webster has employed the following 
method : 

" The patient is placed on a Bolt operating table in the lithotomy 
position, the ankles being fastened to upright rods, the buttocks 
projecting slightly over the end of the table resting on a rubber 
pad. A steel bar, with two padded supports, is attached to the top 
of the table so as to support the shoulders. After the external 
genitals and vagina are cleansed the patient is enveloped in sterile 



426 DIAGNOSIS OF DISEASES OF THE V BINARY SYSTEM. 

sheets, the urine is withdrawn from the bladder, the urethra is 
dilated to the necessary size, and a speculum containing its obturator 
introduced into the urethra. By means of a crank the top of the 
table is turned on a transverse axis so that the lower end is elevated 
and the upper end depressed. The patient is thus made to rest on 
an inclined plane, being held by the shoulder supports, her trunk 

Fig. 200. 





Introducing searcher into left ureteral orifice. (Kelly.) 



being flat against the table and not bent in any way, so that her 
respiration is free and the anaesthetic easily administered. The 
table-top is usually raised until its lower end is twenty-three inches 
above the normal level. The obturator is then removed from the 
speculum, allowing air to enter and dilate the bladder. The exam- 
ination of the bladder and ureters is then carried out, the examiner 
standing on a stool so the eyes may be well above the outer end of 
the speculum. 



DIAGNOSIS OF DISEASES OF URETHRA AND BLADDER. 427 

" This posture has all the advantages of the genupectoral position 
and none of its disadvantages. In difficult cases in which the dis- 
tention of the bladder has not been thoroughly satisfactory, I have 

Fig. 20L. 




Bolt table for cystoscopic examination. 



not been able to get better results by trying the genupectoral posi- 
tion." 

Dilating the Urethral Orifice. The dilators are lubricated with 
boroglycerin and introduced into the urethra by a boring motion. 



428 DIAGNOSIS OF DISEASES OF THE URINARY SYSTEM. 

It is well to first calibrate the urethral orifice in order to select 
the proper size of dilator. The small end of the conical dilator 
is crowded into the urethra until it meets with resistance. The 
index finger is so placed as to mark the point in contact with the 



Fig. 202. 




Cystoscopic examination. (Webster.) 



urethral orifice. The dilator is withdrawn and the index finger is 
found to point to the number of millimetres. Anything below ten 
millimetres will probably require dilating. A dilator slightly less 
in diameter than the calibrator is chosen and larger dilators are 



DIAGNOSIS OF DISEASES OF URETHRA AND BLADDER, 429 

successively employed until the diameter of the urethra is increased 
to the desired degree. Where the orifice is unusually resistant and 
small, Simon suggests cutting it posteriorly. 

Fig. 203. 




Hand holding cystoscope in act of introduction. (Kelly.) 



INTRODUCTION OF THE SPECULUM. 



The size of the speculum should vary from 7 to 12, according to 
the case. When the urethra is small and sensitive, No. 7 or 8 may 
best answer the purpose. With experience a No. 10 will be satis- 
factory in the majority of cases. The urethral orifice is cleansed 
with boric acid, an assistant holds the labia and buttocks apart, 
while the operator grasps the speculum, as shown in Fig. 202, 
and gently forces it through the urethra into the bladder. The 
obturator is held in place by the thumb until the cystoscope has 
entered the bladder, when it is withdrawn. A head mirror reflects 
the light from an electric drop lamp. 



430 DIAGNOSIS OF DISEASES OF THE URINARY SYSTEM. 

The interior of the bladder should be explored systematically, 
moving the speculum from side to side and up and down as the 
occasion requires. 

The Segregate. By this ingenious instrument, first introduced 
by Harris, and modified by Downes, the urine is separately collected 
from each ureter as it passes into the bladder. 

Fig. 204. 




Knee-breast position. CystoscOpe introduced ; sound shows position of anal orifice (Kelly.) 



Two catheters are arranged side by side within a flattened tube, 
each separate and movable on its longitudinal axis. When intro- 
duced into the bladder the catheters are rotated outward on their 
long axes and separated at the bladder end. A metallic lever 
introduced into the vagina of the female and into the rectum 
of the male provides a water-shed in the bladder, on either side 



DIAGNOSIS OF DISEASES OF URETHRA AND BLADDER. 431 

of which the urine is collected from the corresponding kidney. 
The urine flows through the catheters into bottles. 

Fig. 205. 




Downes' segregator. 



The application of the segregator is simple and has the great 

advantage of collecting the urine from either kidney separately 

without catheterizing the ureters. However, it has not proven of 
universal value. 



Pig. 206. 




Eelly-Pawlik method of cystoscopy. The hips are elevated, the bladder is distended with 
air, the cystoscope is inserted into the bladder, and artificial light is directed through the 
cystoscope into the bladder. 



432 DIAGNOSIS OF DISEASES OF THE URINARY SYSTEM. 

MALFORMATIONS AND DISEASES OF THE FEMALE URETHRA. 

I. Congenital malformations of the urethra are uncommon. 
They consist of partial or complete absence of the urethra, atresia, 
displacements, epispadias, and hypospadias. 

1. Partial or complete absence of the urethra may occur in the 
presence or absence of other congenital malformations of the 
genito-urinary tract. All trace of the urethra may be wanting, in 
which case the bladder and vagina may form a single cavity. 

2. Atresia of the urethra as a congenital defect is almost invariably 
associated with malformations of the bladder, vagina, and uterus. 
An outlet for the bladder is commonly found to communicate with 
the vagina or through the patent urachus to the navel. If no such 
communication exists the bladder, ureters, and kidneys will be 
widely distended. 

3. Displacements of the urethra are very uncommon as a congenital 
defect, but are occasionally observed as an acquired one (vide infra). 

4. Epispadias, including a defect in the upper wall of the urethra, 
a division of the clitoris, and a separation of the labia minora, is 
exceedingly uncommon. As associated defects may be mentioned 
separation of the symphysis and an exstrophy of the bladder. 

5. Hypospadias is a defect in the lower wall of the urethra, 
thereby establishing a communication between the urethra and 
vagina. 

II. Acquired malformations of the urethra are dilatations, 
strictures, diverticula, dislocations, and prolapsus. 

1. Dilatation of the urethra may be confined to any portion of or 
involve all of the urethra. Dilatation of the entire urethra is 
usually the result of coitus or masturbation per urethram ; more 
rarely from the presence of a new-growth and foreign bodies. The 
partial incontinence of urine following repeated labors is undoubt- 
edly due to injury to the circular fibres of the urethra. Inconti- 
nence of urine is an almost constant accompaniment. 

Local dilatation of the urethra, known as a urethrocele or diver- 
ticulum, affects the posterior wall of the urethra immediately back 
of the meatus. But few cases are recorded. 

2. Stricture of the female urethra is uncommon as compared with 
men. The causes of these strictures are : 

a. Cicatrization in the anterior vaginal wall following injuries 
through labor. 



DIAGNOSIS OF DISEASES OF URETHRA AND BLADDER. 433 

b. Chronic urethritis, usually of gonorrhoeal origin, is the most 
frequent cause of stricture in the female as well as in the male. 

c. Tumors of the urethral wall rarely constrict the urethra. 

d. Tumors about the urethra and displaced uteri may directly 
constrict the urethra. 

e. Cicatrization following a chancre. 

/. Contraction of the urethra without an assignable cause. 

The diagnosis is made from the difficulty and pain experienced 
in urinating and from the character of the flow, which comes in a 
fine stream or in drops. Not only the existence of a stricture but its 
size, exact location, and the calibre of the urethra are diagnosed by 
calibrating with bougies and by direct inspection through the 
urethroscope. 

3. Dislocations of the urethra may occur in any direction, and 
such dislocations may involve the entire thickness of the urethral 
wall or merely the mucous membrane. Displacements of the 
urethra are not common, because of the anatomical relations. It 
is a short canal lying immediately underneath the symphysis and 
firmly embedded in connective tissue. Misplacement of the who]e 
urethra is the usual occurrence and is almost invariably secondary 
to a displacement of the bladder, as commonly observed in a vesico- 
cele. Inspection and the use of the sound demonstrate the exact 
position of the urethra. The external orifice is directed forward and 
upward and the internal orifice backward and downward. The 
urethral canal may be so distorted as to render the passing of a 
catheter or sound difficult. Great difficulty may be experienced in 
voiding the urine. 

The urethra may be elongated and elevated by tumors which 
draw the bladder upward, by extreme distention of the bladder, and 
by the pregnant uterus. 

4. Prolapse of the urethral mucous membrane results but rarely, 
and in patients who have long suffered from dysuria and vesical 
catarrh. Displacements of the uterus and anterior vaginal wall 
are frequent accompaniments. Near the urethral orifice the mucosa 
is loosened and is protruded from the urethral orifice as a pale red 
or bluish, annular, or crescent-shaped fold of mucous membrane. 
This condition may occur at any age, but is more common in girls 
of a generally weakened constitution. 

Urethritis. In the female as in the male, gonorrhoea is the com- 
mon cause of urethritis. In the absence of an established* cause for 

28 



434 DIAGNOSIS OF DISEASES OF THE URINARY SYSTEM. 

urethritis the lesion is assumed to be gonorrhoeal in origin. Long 
after all clinical evidences of urethritis have disappeared, the gono- 
coccus may inhabit the mucosa. Steinschneider examined thirty- 
four cases of recent gonorrhoeal infection, and found the gonococcus 
in the urethra in all of them. 

Sometimes the purulent secretion is seen to exude from the 
urethral orifice, but, as a rule, it is demonstrated by milking the 
urethra. So characteristic is a purulent discharge from the urethra 
and so seldom is it found in other than gonorrhoeal infection, that 
it may be regarded as almost conclusive evidence of the gonorrhoeal 
nature of the lesion. A cover-slip preparation of all secretions of 
the urethra should be made, and at the same time of any existing 
secretions from the cervix. Tf, as stated by Kelly, the gonococcus 
is found in the secretion of the cervix and not in the urethra, a 
complicating urethritis may be assumed to be also due to gonorrhoea. 
Suchanek found in 166 cases both the vagina and the urethra 
affected in 122 and urethral gonorrhoea existing singly in only 3 cases. 

No effort will be made to make a clinical distinction between the 
hypersemic and the inflammatory lesions of the urethra. They are 
dependent upon the same underlying causes and only differ in 
degree. Hence as additional causes which occasionally operate to 
bring about a congested or inflamed urethra may be mentioned 
diseases of the bladder and kidneys which extend to the urethra or 
in which the urine irritates the urethra. The mechanical irritation 
of the catheter and infections acquired by the use of unclean 
catheters are occasional sources. A urethritis sometimes complicates 
the infectious and contagious diseases. The wearing of an ill- 
fitting pessary, the habit of masturbation, and of excessive sexual 
intercourse may result in urethral congestion. 

Urethritis is acute and chronic. 

1. Acute Urethritis. In this stage it is well to limit the local 
examinations as far as possible. Under normal conditions the 
mucous membrane is pale red in color and there is a slight glairy 
secretion. In the acute inflammatory stage the mucosa about 
the urethral orifice appears red and swollen, sensitive to pressure, 
and secretes a variable amount of pus. 

In acute gonorrhoeal infection of the urethra there is at first a 
prickly, burning pain during and immediately following urination. 
Dysuria and frequent urination are constant symptoms. Three or 
four days later there appears at the urethral orifice a serous, sticky > 



DIAGNOSIS OF DISEASES OF URETHRA AND BLADDER. 435 

transparent secretion, which by the eighth day becomes greenish 
and purulent and continues so for about two weeks, when it decreases 
in amount/ and by the end of the first month may have entirely 
disappeared. A^ivid red points are often seen about the meatus 
which mark the mouths of infected glands. The discharge may 
cause an intense itching about the vulva. When it is desired to 
inspect the urethra a 10 per cent, solution of cocaine should be 
applied to the orifice by a swab before introducing the urethroscope. 
Slight bleeding will be caused by the instrument. The congested 
mucous membrane will not appear so reddened because of the 
pressure of the instrument. 

2. Chronic urethritis exists as a diffuse and circumscribed lesion 
easily recognized through the urethroscope. The initial stage may 
be an acute infection, but more often it is chronic from the begin- 
ning. The secretion is limited ; the mucosa is but slightly swollen 
and is of a livid blue color. There is little or no sensitiveness to 
pressure. 

NEW-GROWTHS OF THE URETHRA. 

New-growths of the urethra are more common in the female than 
in the male. The following forms have been described : 

1. Caruncle. 

2. Fibroma. 

3. Carcinoma. 

4. Sarcoma. 

1. Caruncle. Vascular tumors of the urethra, the so-called 
caruncles, are most frequent. No age is exempt, but they are more 
common in advanced years. They are located at the urethral 
orifice, sometimes extending into the urethra. They are sessile or 
pedunculated, the form varying from flat and nodulated to pedun- 
culated and crenated. The growth is very vascular, bleeding freely 
to the touch, and is sensitive to pressure. The orifice is covered 
with pavement epithelium. In the connective tissue stroma is an 
abundant distribution of nerve filaments and capillary bloodvessels, 
this supply of nerves accounting for the great sensitiveness to 
pressure and the pain in urinating. Sexual intercourse becomes 
intolerable, and the suffering racks the constitution. 

The diagnosis can be made by direct inspection. Where doubt 
exists as to the character of the growth a microscopic section of the 
excised tumor should be made. 



436 DIAGNOSIS OF DISEASES OF THE URINARY SYSTEM. 

2. Fibroma. But few cases are recorded. 

3. Carcinoma of the urethra is rarely primary, but is not infre- 
quently secondary to carcinoma of the vagina, cervix, and vulva. 
I am able to find only twenty-eight cases of primary carcinoma of 
the urethra in the literature. The reported cases show a variety of 
anatomical forms : the papillomatous, nodular, smooth and infil- 
trating, and, finally, the ulcerative. Almost all arose late in life, 
as is common with carcinoma. 

The patient complains of burning and smarting while urinating ; 
later there is more or less bleeding. The endoscope should be 
used in all cases when complaint of such symptoms is made. When 
in doubt as to the character of the growth a portion may be excised 
or scraped from the suspected area and submitted to a microscopic 
examination. 

4. Sarcoma. But four cases of primary sarcoma of the urethra 
have been described. One was a myxosarcoma, another a melano- 
sarcoma. 

URETHRAL FISTULA. 

A fistula of the urethra leading into the vagina is a very unusual 
accident of labor. It is more often artificially induced in the treat- 
ment of dysuria (Emmet's button-hole operation). 

Fig. 207. 




1. Vesicouterine fistula. 2. Vesico-utero vaginal fistula. 3. Vesicovaginal fistula. 4. Urethro ■ 
vaginal fistula. 5. Rectovaginal fistula. 6. Perineo-anal fistula. 7. Anal fistula. (Dudley.) 



DIAGNOSIS OF DISEASES OF URETHRA AND BLADDER. 437 

These fistula seldom assume large proportions, often no larger 
than a pinhead. They are usually located in the floor of the 
urethra ; those artificially induced are situated well forward, while 
those caused by labor are usually found near the sphincter vesicae 
and may involve part of the bladder. 

Foreign bodies in the urethra are rarely found. They are intro- 
duced from without in masturbating or in the passage of sounds and 
catheters, or a vesical stone may lodge in the urethra. 

The diagnosis is based upon the complaints of frequent painful 
urination, the presence of pus, blood, and mucus in alkaline urine, 
and the finding of the foreign body by palpating the course of the 
urethra through the vagina, by sounding the urethra, and by means 
of the urethroscope. 

Calculi in the urethra are almost invariably composed of phos- 
phates. 

DISEASES OF THE BLADDER. 

The vesical diseases of women differ materially from those of 
men, and are deserving of special consideration. We will consider : 

1. Developmental deformities. 

2. Malpositions and malformations. 

3. Foreign bodies. 

4. Traumatisms. 

5. Inflammations. 

6. New formations. 

1. DEVELOPMENTAL DEFORMITIES. 

(a) Vesical fissure (exstrophy) is the most frequent and important 
of the congenital deformities of the bladder. It depends upon a 
deficiency of the anterior wall, and is mostly associated with develop- 
mental defects in the genital organs. Various grades of this mal- 
development are observed. It may consist of a simple cleft of the 
most dependent portion of the bladder or is less frequently located 
near the umbilicus. In the other extreme may be found an absence 
of the entire anterior wall of the bladder. A corresponding portion 
of the abdominal wall is cleft and the gap is filled with a swollen, 
red, mucous membrane continuous with the external skin. The 
pubic bones are separated one-half to three inches and are connected 
by a fibrous band. The urethra is usually wholly wanting and not 



438 DIAGNOSIS OF DISEASES OF THE URINARY SYSTEM. 

infrequently the clitoris is bifurcated. It is possible for the vagina 
and uterus to be divided by a septum, or for two separate vaginae 
and a bicornuate uterus to exist in connection with the fissured 
bladder. At times the posterior wall of the bladder inverts 
through the abdominal fissure. According to Voss, a distended 
bladder in the foetus accounts for these deformities. The dis- 
tended bladder forces the horizontal rami of the pubes apart, then 
ruptures and establishes a communication between the bladder 
and the abdominal cleft. 

The diagnosis is based upon direct inspection of the protruding 
bladder. The red mucous membrane of the bladder is sensitive 
to the touch, the ureteral openings may be visible, and urine may 
be seen dribbling from the ureters. The lower margin of the 
fissure is reddened, eroded, burning and itching from irritating 
urine. 

As to frequency of occurrence, Winckel reports two observed 
cases, and Sickel found two cases in 12,689 newborn children. 

(b) Double bladder is due to a failure of the two parts of the 
allantois to fuse in early foetal life. But few cases are recorded. 

(c) Loculate Bladder. Projections are sometimes seen on the 
outer surface of the bladder formed by diverticuli of the bladder 
wall. They are congenital defects, and are not to be confounded 
with diverticula of inflammatory origin. They have been mistaken 
for supernumerary bladders. 

2. MALPOSITIONS AND MALFORMATIONS OF THE BLADDER. 

The female bladder is subject to malpositions and malformations 
to a far greater degree than is that of the male. 

The normal position of the bladder is in the median line. In 
moderate distention the greatest diameter is transverse, and in 
extreme distention the greatest diameter is the vertical. The 
distended bladder may incline considerably to the right or left of 
the median line and may reach the level of the umbilicus. The 
author recalls seeing in Vienna a postmortem examination of a 
patient in whom the bladder had been opened and stitched to the 
abdominal wall in the right lower quadrant of the abdomen. The 
bladder, which was greatly distended, lay to one side of the median 
line and was thought to be a broad ligament cyst. The mistake 
was discovered in the postmortem examination. 



DIAGNOSIS OF DISEASES OF URETHRA AND BLADDER. 439 

Elevation of the bladder occurs when the pelvis is filled with a 
tumor mass and when the uterus greatly enlarges and extends into 
the abdominal cavity, dragging the bladder with it even to the 
level of the umbilicus. When the elevated bladder is partly filled 
with urine it forms a protruding, fluctuating swelling in front of 
the tumor. 

Downward displacement of the bladder (cystocele) is the most 
frequent malposition, and 'is the result of injury to the pelvic floor 
and of an increase in intra-abdominal pressure. It is most unusual 
for a cystocele to exist in a nullipara. Occupations which involve 
much standing and lifting predispose to cystocele, even in nulliparae. 

In slight degrees of descent the lower part of the bladder is 
somewhat sunken, and in extreme cases the bladder becomes shaped 
like an hour-glass, being divided into an upper and lower part by 
the urethra. In extreme grades associated with prolapsus uteri, 
the urethra may run vertically, the external orifice pointing directly 
upward. Yirchow, Philips, Braun, and others have observed 
dilated ureters and hydronephrosis as the result of obstruction to 
the flow of urine through the stretched and twisted ureters. 

The diagnosis is largely based upon the physical findings ; the 
complaints of the patient will give but little clue to the diagnosis. 
There is a frequent desire to urinate, and this is associated with 
more or less pain. Advanced cases may continue with little or no 
disturbance of the bladder functions. A number of cases of cysto- 
cele have been reported in which the passage of the child was 
impeded. The patient, when she is first aware of the protruding 
vaginal wall, regards it as " falling of the womb." 

With the patient in the lithotomy position the labia are separated 
and she is instructed to bear down. The anterior vaginal wall 
suddenly bulges into a rounded mass, which, if filled with urine, 
will fluctuate when grasped by the fingers. A metallic sound 
placed in the bladder will demonstrate the pouching of the bladder 
into the vaginal tumor. 

When a cystocele is observed the examination is not complete 
until the position of the uterus, the conditions of the pelvic floor, 
and the urine are carefully determined, because malpositions of the 
uterus, injuries to the pelvic floor, and chronic cystitis are almost 
constantly associated with cystocele. 

Eversion of the bladder through a dilated urethra is rarely 
observed. Before such an event can occur there must be a relaxed 



440 DIAGNOSIS OF DISEASES OF THE URINARY SYSTEM. 

bladder wall and a dilated urethra, which, together with an increase 
in the abdominal pressure, may produce the condition. A sound 
passed through the urethra will demonstrate the absence of the 
bladder. Reducing the protruding mass, the bladder is restored to 
its normal position. 

Hernia of the bladder through the inguinal or femoral rings and 
through the foramen ovale have been observed. 

3. FOREIGN BODIES IN THE BLADDER. 

Winckel divides the foreign bodies found in the bladder into 
those that originate in the organ itself, those that come from other 
parts of the body, and those that are introduced from without. 

(a) Foreign bodies originating in the bladder are in large part 
vesical calculi. Calculi may arise from the precipitation of urinary 
salts independent of the previous existence of a foreign body, or 
they may have as nuclei certain foreign elements introduced into 
the bladder from without or from the upper urinary tract. They 
are not so common in the female as in the male, because of the 
shortness of the urethra, the rarity of urethral strictures, and the 
readiness with which lesions of the female bladder are cured. 

In 1792 cases of vesical calculi found in Moscow by Dr. Klein, 
only four occurred in women. In 10,000 women examined by 
Winckel from 1860 to 1884, only once did he find calculi in a 
woman. In 3500 autopsies done upon women in the Dresden City 
Hospital, stone in the bladder was found six times. These statistics 
speak for the infrequency of vesical calculi in women. 

The calculi are usually lodged in the fundus immediately back of 
the trigone. Not infrequently they lie in the pouch of a cystocele. 

In the only case observed by the author a cystocele was filled 
with about twenty stones varying in size up to that of a hickory- 
nut. These were found in a woman, aged sixty-five years. A 
fistulous communication had developed in the cystocele, and 
through it the stones were extracted. 

The stones vary in number, size, color, consistency, and com- 
position. They have been known as large as a child's head. 
Hugenberger removed one weighing three and one-half pounds. 
Hundreds of stones may be present at one time in the bladder. 
They are composed of phosphates, urates, oxalates, and rarely of 
cystin. 



DIAGNOSIS OF DISEASES OF URETHRA AND BLADDER. 441 

(b) Foreign bodies in the bladder that originate from other parts of 
the body are the oxalic and uric acid calculi coming from the 
kidney, the contents of ovarian cysts which have ruptured into the 
bladder (teeth from dermoid cysts have formed the nucleus of 
stone), the products of extra-uterine pregnancy following rupture 
of the gestation sac into the bladder, fecal matter from an ulcerated 
bowel, and echinococci. 

(c) Foreign bodies in the bladder introduced from without are por- 
tions of catheters, sutures, hairpins, pessaries which have ulcerated 
through the vesicovaginal septum, toothpicks, and the like. 

The diagnosis of foreign bodies in the bladder is based upon the 
patient's complaint of an irritable bladder ; later, on the clinical 
evidences of cystitis, and, finally and conclusively, upon the finding 
of a foreign body within the bladder by palpation and inspection, 
or upon the spontaneous expulsion of the body. 

If the body is large it may be palpated through the vagina. A 
sound passed into the bladder will often disclose the presence of a 
foreign body. By inspection of the interior of the bladder not only 
the presence of a foreign body is determined, but also the character, 
number, size, form, and exact location. Direct inspection is of 
special value where the stone lies in a diverticulum beyond the 
reach of the sound. Fine gravel, too fine to be detected by the 
sound, is also demonstrated by the cystoscope. !Not only the pres- 
ence of a foreign body, but the accompanying cystitis is recognized 
by the aid of the cystoscope. Irritation of the bladder by the 
foreign body may render the viscus too sensitive for a cystoscopic 
examination without general anaesthesia. 

4. VESICAL FISTULA. 

By means of a fistula a communication is established between 
the bladder and the vagina, uterus, or intestine. 

(a) A vesicovaginal fistula is most often the result of traumatism 
during labor. Protracted parturition, in which the head firmly 
presses upon the vesicovaginal septum, destroys the vitality of the 
tissues and leads to a sloughing, with the formation of a permanent 
fistulous communication between the vagina and bladder. I have 
at the present writing a case under observation in which the vesico- 
vaginal fistula was caused by direct violence during the attempted 
delivery of a child. It is seldom, however, that fistulas are caused 



442 DIAGNOSIS OF DISEASES OF THE URINARY SYSTEM. 

by direct violence in the use of forceps. More often, as Kelly 
puts it, " they are clue not to the use of forceps, but to the too long 
delay in using them." 

Carcinomatous invasion of the vesicovaginal septum is second in 
point of frequency. Other causes are vesical calculi, injuries sus- 
tained in vaginal operations, and ulceration from the pressure of 
an ill-fitting pessary. Forced catheterization during labor may 
perforate the bladder. Finally, pelvic abscesses may perforate both 
into the bladder and vagina, thereby forming a vesicovaginal fistula. 



Fig. 208. 




,;K>.vh 



Vesicovaginal fistula. A communication is established between the base of the bladder and 
the vagina at a midpoint in the anterior wall of the vagina. 



The diagnosis of vesicovaginal fistula is made by the history of a 
possible cause, the complaint of incontinence of urine with its dis- 
agreeable consequences, and, finally, by direct inspection. 

It is unusual for a fistula developing after labor to manifest 
itself before the end of the first week, though it is possible for urine 
to escape through the vesicovaginal septum during labor. 

The symptoms are quite characteristic. Before the urine escapes 
through a fistula there are usually symptoms of cystitis, bloody 
urine, and rise of temperature. A foul-smelling vaginal discharge 
indicates the sloughing of the vaginal wall, and this is soon fol- 
lowed by a dribbling of urine into the vagina. The vagina, vulva, 



DIAGNOSIS OF DISEASES OF URETHRA AND BLADDER. 443 

perineum, and inner aspect of the thighs soon show the irritating 
effect of the urine in the form of vulvovaginitis and local dermatitis. 
The distress and inconvenience of the dribbling lowers the vitality 
of the patient, and she may become extremely w T eak and emaciated. 
Such individuals are almost invariably sterile. Menstruation may 
be absent, irregular, or painful, but may also be perfectly normal. 
When the fistula is high up and small, the disturbance may be 
slight and the general health unimpaired. 

Difficulty in voiding urine, following labor, should always sug- 
gest the possible development of a urinary fistula. Under such 
circumstances it is well to avoid vigorous manipulation for fear of 
creating or extending a fistula in tissue already devitalized. 

Fig. 209. 




Vesicouterine fistula. A communication is established between the fundus of the bladder 
and the uterus at about the level with the internal os. 



Palpation of the fistula seldom affords satisfactory information 
when the tissues about the fistula are soft and necrotic. This is 
particularly true of a small opening. In long-standing cases the 
puckered scar tissue and an opening possibly filled with soft raucous 
membrane may often be recognized. 

A sound placed in the bladder and the index finger of the 
opposite hand in the vagina may be brought together through a 
fistulous opening. 

Inspection will give positive information as to the location and 



444 DIAGNOSIS OF DISEASES OF THE URINARY SYSTEM. 

size of the fistula. A Sims speculum introduced into the vagina 
will expose the fistula if large enough. Sterilized milk or some 
colored aseptic fluid injected into the bladder may be seen to flow 
through the fistula. The cystoscope will expose the opening from 
the vesical side, and at the same time afford information respecting 
the condition of the bladder — whether cystitis exists and foreign 
bodies lie within. 

Having established the diagnosis of vesicovaginal fistula, it 
becomes important to consider the nature of its borders, their 
fixation, tension, and the possible existence of other fistulse. 

Fig. 210. 




Cervico-vesico-vaginal fistula. A communication is established between the cervical canal 

vagina, and bladder. 

(b) Vesico-uterine Fistula. When a laceration of the cervix 
extends into the lower uterine segment and the adherent bladder, 
it is possible for healing to be complete in the lower portion of the 
wound, leaving a fistulous opening above between the uterus and 
bladder. 

The urine may be discharged in part through the cervix and in 
part through the urethra, depending upon the size of the fistulous 
opening and the position of the patient. To demonstrate a com- 
munication of the bladder with the uterus, inject sterile milk or 
sterile-colored fluid into the bladder and observe through a speculum 
that the fluid escapes from the cervix. To demonstrate that it is 



DIAGNOSIS OF DISEASES OF URETHRA AND BLADDER. 445 

not a uretero-uterine fistula observe that the flow of urine from 
the cervix is not intermittent. Catheterizing the ureters will 
demonstrate them to be intact. 

(c) Vesicocervical Fistula. Likewise in extensive lacerations of 
the cervix involving the supravaginal portion and the base of the 
bladder a fistulous communication between the cervical canal and 
the bladder may persist. Such fistulse are demonstrated in a 
manner similar to that indicated in vesicouterine fistula. 

5. CYSTITIS. 

Cystitis is an inflammatory lesion of the bladder due to invasion 
of the walls of the bladder by pathogenic micro-organisms. 

Etiology. In 2500 postmortem examinations of women, cystitis 
was found sixty-eight times (2.7 per cent.). 

Virchow holds that the urine must first become animoniacal, and 
by its irritating effects cause the epithelium to become loosened 
before bacteria can gain a lodgement in the bladder wall. Under 
apparently normal conditions the urine may contain bacteria, hence 
there must exist a predisposing cause for cystitis before the bacteria 
manifest their pathogenic properties. 

As predisposing causes of cystitis may be mentioned congestion 
due to overdistention of the bladder, the presence of foreign bodies 
in the bladder, structures crowding upon the bladder from with- 
out (displaced uteri, pelvic exudates, and tumors), traumatisms 
sustained in labor and surgical operations, the passage of catheters 
and sounds, ill-fitting pessaries, the irritating influence of internal 
remedies, of fluids injected into the bladder, and of toxins developed 
within the body in the course of infectious diseases and intestinal 
disturbances. Congestion of the bladder from any of the above- 
named causes will prepare the tissues for invasion by pathogenic 
micro-organisms. 

The micro-organisms found in the inflamed bladder are the 
staphylococcus pyogenes aureus, albus, and citreus ; streptococcus 
pyogenes, bacillus coli communis, gonococcus, bacillus tuberculosis, 
bacillus typhosis, and numerous micro-orgaoisms of lesser clinical 
importance, as, for example, the bacillus aerogenes capsulatus of 
Welsh, diplococcus urese pyogenes, cocco-bacillus, urea pyogenes, 
and the urobacillus liquefaciens. 

Not infrequently two or more of the above-named bacteria are 
found in the same case. There is a condition known as baderiuria, 



446 DIAGNOSIS OF DISEASES OF THE URINARY SYSTEM. 

in which the urine swarms with bacteria in the absence of any con- 
siderable amount of pus or other foreign elements. 

The avenues by which these micro-organisms enter the bladder 
are : 

1. The urethra, the most common of all. Micro-organisms 
which always exist in large numbers in the urethra, vagina, and 
vulva may be carried by instruments through the urethra and into 
the bladder. It is possible for bacteria to pass through the urethra 
into the bladder without the introduction of instruments. This is 
notably true of the gonococcus. 

2. The kidney, when infected, may involve the bladder through 
the medium of the urine. It has been demonstrated that the urine 
may convey pathogenic micro-organisms to the bladder and there 
cause an infection without deranging the kidney. 

The colon bacillus and tubercle bacillus probably most often gain 
access to the bladder from the blood by way of the kidney. 

3. The bowel, when adherent to the bladder, may transmit the 
colon bacillus and other micro-organisms to the viscus. 

4. Inflammatory areas surrounding the bladder and intimately 
connected with it may be the sources of infection, as, for example, 
pelvic abscesses, suppurating dermoid cysts, pyosalpinx, and 
perityphlitic abscesses. 

5. Hmmatogenous infection of the bladder is an infrequent mode, 
though fully demonstrated. 

The following summary is from Kelly : 

1. Cystitis is always caused by the presence of bacteria. 

2. The mere presence of bacteria is insufficient to cause a cystitis ; 
a further predisposing cause is necessary. 

3. There are various modes of entrance for bacteria : through 
the urethra, through the ureter from the kidney directly, from 
inflammatory areas in the uterus or Fallopian tubes, and probably 
from the rectum under similar conditions ; still another probable 
avenue of entrance is through the blood. 

4. Under favorable conditions any pathogenic organism may 
give rise to cystitis. 

Anatomical Diagnosis. With the exception of the tubercle 
bacillus the anatomical changes do not differ essentially in the 
various kinds of infections. 

Kelly classifies cystitis as diffuse, circumscribed, and scattered,, 
and calls attention to the important and often overlooked fact that 



PLATE XLII. 

Figure 1. Cystitis originating in the Trigone and extending to 
adjacent surfaces. Magnified. 




Figure 2. Normal Bladder Mucosa. Magnified. 



PLATE XL1II. 

Figure 1. Linear Ulcer of Bladder Mucosa. Magnified. 




Figure 2. Ulcerated Patches in the Trigone. Magnified. 



DIAGNOSIS OF DISEASES OF URETHRA AND BLADDER. 447 

cystitis is not always a disease of the entire mucosa of the bladder, 
but is more often found in patches with normal mucous membrane 
intervening. This fact speaks for the efficacy of direct applications 
to the involved areas rather than to the entire surface by injections. 

Both acute and chronic lesions are recognized. 

In acute cystitis the bloodvessels are prominent, causing a swell- 
ing and reddening of the mucosa ; small hemorrhages are frequently 
seen. 

In the chronic stage the reddening is less intense ; the mucosa 
appears grayish and is thrown into folds. Papillomatous eleva- 
tions may appear on the surface, and over the surface may be a 
deposit of pus, degenerated epithelium, micro-organisms, and salts, 
forming a false membrane which adheres rather firmly to the mucosa. 

In cases of long standing the muscular wall of the bladder may 
be involved, being greatly thickened and giving rise to trabecule of 
muscle bundles intersecting at various angles. Abscesses may 
develop in the w T all, and superficial ulcers are not infrequently seen 
on the mucosa. The entire mucous membrane may be thrown off 
in the so-called exfoliative cystitis. 

Clinical Diagnosis. Frequent painful urination characterizes 
cystitis. The voiding of urine affords very little relief in the 
marked cases. The patient may suffer from a constant desire to 
urinate. The amount of urine voided may be no more than a few 
drops, and this may be passed every few minutes. It is possible 
for cystitis with marked changes to exist in the bladder wall with- 
out seriously disturbing the functions of the bladder. The tempera- 
ture and pulse are seldom influenced unless the urethra or kidneys 
are involved. The bladder is tender to pressure, and an attempt to 
catheterize the bladder or to pass the sound into it causes suffering, 
and should not be done without local or general anaesthesia. 

The diagnosis is made from a history of the above symptoms, 
from an examination of the urine, and from direct inspection. The 
urine is usually alkaline in reaction, though sometimes acid, and 
contains albumin, pus, bladder epithelium, crystals of triple phos- 
phates, a variety of micro-organisms, membranous shreds, and 
occasionally some blood. When the bacteria are found in pure 
culture or vastly predominating over other forms they are the 
probable cause of the infection. The presence of the gonococcus or 
the tubercle bacillus in the urine is conclusive evidence of the true 
underlying cause. 



448 DIAGNOSIS OF DISEASES OF THE URINARY SYSTEM. 

The clinical distinction between the acute and chronic forms of 
cystitis is in duration and in the intensity of the symptoms. They 
are dependent upon the same underlying causes. 

The cystoscopic diagnosis of cystitis is often difficult and may be 
impossible, but, as a rule, the results are readily obtained and are 
conclusive. In acute cystitis the difficulty arises from the pain 
caused by the manipulation of the instrument. Unless the indica- 
tion is urgent no cystoscopic examination should be made, and then 
only under anaesthesia. 

Local anaesthesia at the neck of the bladder may suffice. When 
possible to delay the examination the patient should be confined to 
her bed and sitz baths, diluent drinks, and sedatives administered. 
Chronic cystitis may present equally great difficulties because of 
the contracted bladder and the deposit upon the bladder wall. 

Acute cystitis is recognized through the cystoscope by the prom- 
inence of the bloodvessels in the mucosa. This congestion of the 
mucosa presents a variable shade of red, having an irregular dis- 
tribution over the surface. The more acute the inflammation the 
deeper the color. Hemorrhages into the mucous membrane are 
seen varying in size from a pinhead to a pea, and in color from 
bright red to almost black. They are most often located near the 
mouths of the ureters, but may be found at any point in the mucous 
surface. 

Chronic cystitis presents a paler surface of a grayish color ; the 
bloodvessels are faintly traceable ; hemorrhagic areas are darker 
and smaller than in the acute stage. The surface has lost its lustre 
and presents an irregular appearance. The folding and swelling 
of the mucous membrane may hide the mouths of the ureters, and 
be so enormous as to suggest the possible presence of a new- 
growth. 

There may be no secretion, and, again, the secretion may be 
so abundant and tenacious as to resist all efforts for removal by 
irrigating. Accumulations of the secretion may be mistaken for 
new-growths. Trabecule and diverticula are often seen in cystitis, 
and are largely confined to the inflamed areas. 

Tuberculous Cystitis. It is not sufficient to merely diagnose 
cystitis and to distinguish between the acute and the chronic forms, 
but it is of the greatest importance to recognize, as far as the present 
methods of examination will permit, the bacteriological factors 
involved. This is particularly true of gonorrhoeal and tuberculous 



DIAGNOSIS OF DISEASES OF URETHRA AND BLADDER. 449 

cystitis, since the organisms causing these lesions are well known 
and we are in possession of the means of detecting them. 

Tuberculosis of the bladder is caused by infection through the 
blood, by extension of a tuberculous process from the kidney, the 
genital organs, or peritoneum. The lesion is more often found in 
early and middle life, and is more frequent in the male than in the 
female. It may be the primary infection in the bladder, or other 
micro-organisms may have previously invaded the bladder. A 
mixed infection is common. In tuberculosis of the kidney it is 
possible for tubercle bacilli to pass through the bladder in the 
urine for years without infecting the bladder. As in other forms of 
infection, the healthy, intact mucous membrane resists the invasion 
of the micro-organisms. 

The ureteral openings and the trigone are the most common seats 
of tuberculosis. Grayish tubercles are seen to stud the mucous 
surface, and are usually in groups. Later the tubercles coalesce 
and form cheesy masses, which in turn break down into lenticular 
ulcers with a flat base and sharp, undermined, ragged borders 
within which small tubercles are seen. The ulcers may perforate 
the bladder wall and form fistulous tracts leading to the para- 
vesicular tissue, rectum, and vagina. 

The diagnosis is based upon the clinical evidences of cystitis, 
associated with the presence of tuberculosis elsewhere in the body, 
particularly in the kidney, upon the bacteriological examination of 
the urine, the cystoscopic appearance of the bladder, the micro- 
scopic examination of excised pieces and scrapings reraoved from 
the bladder through the cystoscope or a fistulous opening, and 
upon inoculation experiments. Unimpaired general health does not 
exclude the possible presence of tuberculosis. Renal tuberculosis 
may closely resemble vesical tuberculosis. Only by microscopic 
examination and inoculation experiments with catheterized speci- 
mens of urine is it possible to exclude renal tuberculosis. Careful 
and repeated examinations may be required. 

HYPEREMIA OF THE BLADDER 

Hyperemia, irritable bladder, and neuralgia are terms in common 
usage, and imply a disturbance of the bladder functions with vascu- 
lar congestion of the mucosa. This hyperemia may be diffuse, but 
is more often confined to a definite portion of the bladder, particu- 

29 



450 DIAGNOSIS OF DISEASES OF THE URINARY SYSTEM. 

larly to the trigone. The involved areas are red, swollen, and 
tender to the touch of an instrument. There is no possible way of 
distinguishing such a condition from a mild, localized cystitis. The 
symptoms are identical. Hyperemia of the bladder should be 
diagnosed without difficulty by a cystoscopic examination. 

6. NEW FORMATIONS OF THE BLADDER. 

Tumors of the bladder are more rarely found in the female than 
in the male. Nearly every variety of tumor, both benign and 
malignant, is found in the bladder. Of the benign tumors there 
are myoma, fibroma, papilloma, adenoma, and dermoid cysts, and 
of the malignant tumors carcinoma and sarcoma. 

Fere has shown the places of predilection of tumors in a table 
constructed from the reports of 107 cases. In the 107 reported 
cases, 25 were found in the base of the bladder, 17 in the posterior 
wall, 13 in both the base and walls, 8 close to the left ureter, 5 
near the right ureter, 2 in the anterior wall, 1 in the anterior and 
superior wall, 12 were multiple, and 8 diffuse. 

More than half the tumors of the bladder are single. 

Myoma originates from the muscular wall of the bladder, and is 
composed of smooth muscular fibre and a limited amount of con- 
nective tissue. The tumor is sessile or pedunculated. But few 
cases are reported. 

Fibroma usually appears as a fibrous polyp with a long, slender 
pedicle. The tumor is composed of fibrous tissue. They are rare* 

Papilloma of a benign character protrudes into the cavity of the 
bladder as a wart-like growth, with villous projections on the sur- 
face of the tumor. In the place of villosities there may be nodular 
projections. They are vascular, bleeding freely to the touch. A 
single tuft may be found on the trigone or the entire inner surface 
of the bladder may be covered. Its growth may be slow, extending 
over years with but little increase in size. The tumor is rarely so 
large as a child's fist, and is to be regarded as the most common of 
the tumors of the bladder. 

Adenoma of the bladder is a rare new formation of epithelial 
origin. It is sessile or pedunculated, and seldom attains a large 
size. The histogenesis of the growth is uncertain. 

Dermoid cysts of the bladder have been recorded by Paget and 
Boucher. Their existence has been questioned. Cases are not 



DIAGNOSIS OF DISEASES OF URETHRA AND BLADDER. 451 

wanting in which a dermoid cyst of the ovary has discharged its 
contents into the bladder and there formed a nucleus for vesical 
calculi. 

Carcinoma of the bladder is primary or secondary. In secondary 
carcinoma the primary seat of the lesion is usually in the cervix, 
having spread thence to the bladder by continuity of tissue. It 
exists as a vegetating villous growth or as a diffuse infiltration, and 
is usually multiple. It bleeds freely to the touch and is exceedingly 
friable. Ulceration quickly follows upon infiltration, and there is 
a peculiar tendency on the part of the growth to remain localized 
for a surprisingly long time. Secondary growths are frequently 
found near the primary lesion. 

Sarcoma appears in the female bladder more frequently than in 
the male, and is found at any period of life from childhood to the 
postclimacteric period. These growths are said to be prone to 
extend through the urethra and to appear at the vulva. 

The diagnosis of tumors of the bladder is determined by palpation 
and inspection. The clinical signs in the early stage are about the 
same, whatever the character of the growth. All show more or 
less tendency to bleed. Hemorrhage is the most characteristic 
symptom. The bleeding is increased during the period of menstrual 
congestion, and has been observed to be greatest in the night. Pain 
may be present in the benign as well as in the malignant growths, 
though seldom to so great a degree, but is strangely absent in many 
cases. Late in the course of the lesion emaciation and cachexia 
develop in cases of malignant growths, and serve to distinguish 
these from benign new formations. 

Examination of the urine is of little value in distinguishing 
tumors of the bladder from calculi or cystitis. Evidences of 
cystitis will usually be found in the urine, but this is not invariably 
the case even in the presence of large tumors of long standing. On 
the contrary, the bladder wall may present a normal appearance or 
may be anaemic. The loss of blood may be so great as to produce 
a high degree of anaemia and exhaust the strength of the patient. 
The presence of cylindrical cells in the urine is regarded by some 
authorities as conclusive evidence of the existence of a papillary 
growth. 

Palpation reveals the presence of a foreign growth if it is suffi- 
ciently large. It may be possible to detect infiltration by a malig- 
nant growth in the neighboring tissues. Two fingers inserted into 



452 DIAGNOSIS OF DISEASES OF THE URINARY SYSTEM. 

the vagina and the other hand on the abdomen may engage the 
tumor. A soft, pedunculated growth may elude detection by this 
method. Such soft, pedunculated growths and all small tumors can 
be detected only by a cystoscopic examination. Direct palpation 
of the tumor through the urethra is an obsolete method. 

Direct inspection gives positive evidence of the presence of a 
tumor, of its size, form, color, and location, of the number of growths, 
whether pedunculated or sessile, ulcerated or intact ; also, as to 
whether there exists a cystitis and the extent of the inflammatory 
complications. Through the speculum a piece of the growth may 
be removed for microscopic examination. 



CHAPTER XXXIII. 

THE DIAGNOSIS OF THE DISEASES OF THE URETERS. 

Anatomy. The ureters lie behind the abdominal and pelvic 
peritoneum and are slightly movable, flattened cords, extending 
from the kidney to the bladder. Under normal conditions they 
run symmetrically in an irregular, curved course on either side. 
The average length is ten to twelve inches, the left being slightly 
longer than the right because of the higher position of the left 
kidney. 

There is no variation in the diameter of the ureter except at 
either end, where it distends above into the funnel-shaped pelvis 
and below into the ureteral prominence. The average diameter is 
5 mm. 

The ureters are traced through the pelvis in a sigmoid course. 
They lie close to the posterior lateral wall of the pelvis beneath 
the peritoneum and near the internal iliac artery. From this 
point they turn forward, passing underneath the uterine artery at 
the base of the broad ligament half-way between the cervix and 
the pelvic wall. They then run parallel to the upper anterior 
vaginal wall and enter the bladder at the upper angle of the trigone. 
Through the bladder wall the ureters rim obliquely forward and 
inward. 

The course of the abdominal portion of the ureter, including that 
part running from the kidney to the brim of the pelvis, passes 
forward in a curved direction over the psoas muscle to the brim of 
the pelvis. The ovarian veins and artery join the ureter at a mid- 
point in its course through the abdomen. On the left side it lies 
behind the colon above and the sigmoid below ; on the right side it 
lies behind the caput coli and the ascending colon. 

Physiology. The ureters are not merely passive in conveying 
the urine from the kidney to the bladder. A peristaltic wave 
travels from above downward two or three times each minute, 
imparting to the ureters a vermicular movement and forcing the 
urine onward. 



454 DIAGNOSIS OF DISEASES OF THE URINARY SYSTEM. 

Methods of Examination. Four methods of examining the 
ureters are in general use — palpation, inspection, catheterization, 
and sounding. 

Palpation. It is possible to palpate the pelvic portion of the 
ureter through the vagina and rectum. The abdominal portion of 
the ureter cannot be palpated without making an incision into the 
abdomen or lumbar region. 

In palpating the pelvic portion of the ureter the bladder and 
rectum must be empty, all clothing constricting the waist must be 
removed, and the patient placed in the lithotomy position. 

The index finger is inserted high in the vaginal fornix near 
the side wall of the pelvis. Stroking the vaginal wall downward 
and backward, the ureter is felt as a slender cord which slips away 
from the finger. That portion leading from the base of the broad 
ligament to the bladder is most easily felt. The size, consistency, 
mobility, and direction of the ureter serve to identify it in a vaginal 
examination. 

The tendinous arch of the levator must not be mistaken for the 
ureter, nor must the obturator vessels and nerve. Only when the 
abdominal walls are extremely thin can the ureter be palpated at 
the pelvic brim about one and one-quarter inches to the right or 
left of the promontory of the sacrum. 

When the ureter is diseased the line of tenderness will serve as a 
guide. 

Through the empty rectum and preferably under anaesthesia, the 
ureter can be traced through the pelvis, the left being more acces- 
sible than the right. Guided by the pulsations of the internal iliac 
artery beginning at the bifurcation of the common iliac and tracing 
downward, the finger detects a flat, yielding cord running downward 
and forward. The larger and more resisting the ureter, the more 
easily is it palpated. 

A catheter or bougie placed within the ureter to serve as a guide 
will facilitate the outlining of the ureter. 

Inspection. No portion of the ureter can be inspected without an 
incision except that portion lying in the bladder wall which is 
recognized through the cystoscope as the ureteral prominence. 
"With the abdomen open the lower abdominal portion and the 
upper pelvic portion may be inspected by drawing the sigmoid 
toward the median line. It is possible to lay bare the abdominal 
portion of the ureter by a lateral incision, drawing the ascending or 



THE DIAGNOSIS OF THE DISEASES OF THE URETERS. 455 

descending colon to the median line. In this way the peritoneal 
cavity is not opened. The ureter is found lying upon the psoas 
muscle. 

Catheterization. Both palpation and inspection are of minor 
importance as means of investigating the ureters. Little can be 
positively demonstrated by these methods. By the ureteral catheter 
we may diagnose to a certainty the patency of the ureter, the exist- 
ence of ureteral calculi, foreign growths, strictures, hydro-ureter, 
pyo-ureter, and many of the lesions of the kidney to be considered 
later. 

The urine from either kidney is collected without mixing with 
that of the opposite kidney or with the foreign elements in the 
bladder and urethra. 

By the Xitze method the catheter is introduced through a canal 
in the instrument. The usual technic of a cystoscopic examina- 
tion is carried out. 

In the Kelly-Pawlik method and preferably in the elevated 
lithotomy position, as advised by Webster and Pryor, the 
catheter is directed through an endoscope after a thorough inspec- 
tion of the bladder. In this method the instruments employed are 
a conical urethral dilator, obturators, specula ranging in size from 
8 to 10, head mirror, natural or artificial light, an evacuator, 
searcher, long, curved mouse-toothed forceps, and a flexible ureteral 
catheter. For special purposes there may be added hard-rubber 
bougies, a metal ureteral catheter, and a series of dilating catheters. 
After thoroughly inspecting the bladder as advised by Kelly the 
ureteral orifices are located by what is called a searcher. When no 
difficulty is experienced in locating the ureteral orifice or prominence 
the searcher may be dispensed with and the catheter at once directed 
to the ureter. A metallic searcher is made to lightly impinge 
against the mucous membrane in the supposed location of the 
ureteral orifice. Xo force is to be used for fear of perforating the 
bladder. 

The searcher separates the lips of the orifice, which now present 
a dark, rounded opening, and is allowed to drop into the ureter 
by its own weight. It serves as a guide to the catheter, which 
is directed to the ureteral orifice. As the catheter enters the 
ureter the searcher is withdrawn by an assistant. 

A flexible catheter has many advantages over one made of metal 
or non-flexible rubber. It readilv follows the course of the ureter 



456 DIAGNOSE OF DISEASES OF THE URINARY SYSTEM. 

to the pelvis of the kidney, and there is little danger of injuring the 
ureter. When it is desired merely to catheterize the ureter without 
entering the pelvis of the kidney a shorter catheter may be employed, 
one measuring twelve inches, whereas, it would require a catheter 
twenty inches in length to extend to the kidney. It is essential 
that the catheter have a perfectly smooth surface and a blunt, 
rounded end with an oval eye near the tip. A wire stylet is 
required to give stiffness to the catheter as it is forced through the 
ureter. 

Where the bladder can be inspected without an anaesthetic it is 
usually possible to introduce a catheter without causing great dis- 
comfort. 

It is important to thoroughly sterilize the catheters both before and 
after using. All foreign particles must be removed from the lumen 
of the catheter. This can be done by means of a stylet and by 
forcibly injecting water through the catheter. They should always 
be kept straight, for when allowed to roll up the varnish cracks and 
chips off. When both ureters are to be catheterized the speculum 
is withdrawn and reinserted beside the first catheter. When one 
ureter is catheterized and there is difficulty in passing a catheter 
into the other ureter, a fairly accurate method of separately col- 
lecting the urine is found in completely emptying the bladder, after 
which a large catheter is placed in the urethra. All urine collect- 
ing in the bladder while the ureteral catheter is in place is assumed 
to come from the opposite kidney, and especially is this true when 
the separate collections differ in character. 

When, on account of an infected bladder, it is inadvisable to 
pass a catheter into the ureters, Kelly advises collecting a few 
drops of urine directly from the ureteral openings. This amount 
will serve for a microscopic examination. When the ureter is tor- 
tuous or the calibre is constricted, it may be impossible to introduce 
a flexible catheter. Here a metal catheter will be of service, but 
must be used with caution for fear of injuring the ureter. 

Bougies made of hard rubber, two millimetres in diameter and 
twenty inches in length, are of service in locating ureteral calculi 
and in dilating strictures in the pelvic portion of the ureter. It is 
possible to push the bougies into the pelvis of the kidney without 
inflicting injury. A bulbous enlargement is placed about seven 
millimetres back of the point. These bulbs vary in size from a 
little more than the diameter of the instrument to four millimetres. 



THE DIAGNOSIS OF THE DISEASES OF THE URETERS. 457 

Kelly has ingeniously devised a wax tip for the bougies, by which 
he is enabled to locate calculi in the ureter and pelvis of the kidney. 
Longitudinal grooves are made on the sides of the tip for the pur- 
pose of retaining the dental wax. A silk renal catheter tipped with 
wax will serve the purpose equally well. The scratch marks made 
by the calculi are seen under a low magnifying glass. Where the 
X-ray fails to detect the stone it is often possible to locate it by 
wax-tipped bougies. 

Kelly gives the following summary in a recent article on " Scratch 
Marks on the Wax-tipped Catheter in the Diagnosis of Stone in 
the Kidney or Ureter :" 

(a) The scratch marks afford a valuable confirmation of the find- 
ings of the X-ray plates. 

(6) The wax-tipped catheter serves to distinguish phleboliths 
about the vault of the vagina and in the pelvic veins from ureteral 
calculi. 

(c) In the cases of stout women, where the X-ray findings are 
unsatisfactory and the repeated use of the X-ray is dangerous. 

(d) In cases of uric acid and uratic calculi, where the X-ray 
shadow is faint, leaving doubt as to the diagnosis. 

(e) In extemporized, hurried investigations, when the X-ray 
apparatus is not conveniently accessible, and more especially in 
retrograde catheterization from the pelvis of the kidney downward 
in the course of a renal operation, to determine whether there are 
any calculi lodged in the ureter. 

(/) In fibrous or old inflammatory thickenings about the renal 
pelvis, which give a shadow on the photographic plate exactly like 
a stone. 

Examination of the Urine Collected from the Ureters. Following 
the suggestions of Kelly five things are inquired into in making a 
thorough examination of the urine collected directly from the 
ureter and kidney. 

1. The amount of fluid escaping at once upon the introduction of 
the catheter. 

2. The rate of flow during catheterization. 

3. Physical properties, specific gravity. 

4. Chemical properties. 

5. Bacteriological condition. 

The following points are observed in securing separated urines 
(Kelly) : 



458 DIAGNOSIS OF DISEASES OF THE URINARY SYSTEM. 

1. The exact time of introduction of each catheter is noted. 

2. The time of withdrawal is noted and also written on a card, 
giving the exact duration of the flow. 

3. The exact amount of secretion collected in the test tube is 
noted. 

4. It is well to compare the rate of secretion, determined by 
noting the amount of flow in a given unit of time, say from five to 
fifteen minutes or longer, with the entire amount passed in the 
twelve hours during which the examination is made. If the amount 
secured is too small or too large the error may be rectified in this 
way. A nervous patient, for example, will sometimes pass an 
excessive amount through the catheter. 

5. An analysis of each urine is made, investigating its physical, 
chemical, microscopic, and bacteriological characters. Especial 
attention must be paid to the urea as the most important repre- 
sentative of the physiological activity of the kidney. 

CONGENITAL ANOMALIES IN THE DEVELOPMENT OF THE 

URETERS. 

1. Absence of one or both ureters. 

2. Occlusion of part or all of the lumen. 

3. Double ureter. 

4. Ectopic ureteral orifice. 

5. Dilatation of a partially occluded ureter. 

6. Bending and twisting of the ureter. 

1. Absence of one or both ureters is usually associated with an 
absence of the corresponding kidney. 

2. Occlusion of part or all of the lumen of the ureter is asso- 
ciated with atrophy and cystic degeneration of the corresponding 
kidney. 

3. A double ureter, while not often found, is the commonest of all 
congenital defects in the ureter. The ureter may be double in any 
portion of its course or may begin in separate and distinct pelves 
of the kidney and open separately into the bladder. 

A double ureter may be unilateral or bilateral. The condition 
has no clinical significance. The clinical diagnosis is inferred by 
the discovery of two separate and distinct ureteral openings into 
the bladder and by the passage of bougies and catheters into each 
of the ureters. 



THE DIAGNOSIS OF THE DISEASES OF THE URETERS. 459 

4. An ectopic ureteral orifice presents at a point outside the 
bladder. Very often this is found in the urethra and vagina. 

Incontinence of urine is the complaint of the patient. The 
diagnosis is based upon direct inspection first of the vulva, next of 
the vagina through a speculum, of the urethra through a urethro- 
scope, and, finally, of the bladder through a cystoscope. 

The opening will be recognized as ureteral by seeing an intermit- 
tent flow of urine pass from it. 

To determine whether there is a second ureteral opening on the 
same side a cystoscopic examination is made. A catheter or 
bougie passed into the opening will be directed to the correspond- 
ing kidney. 

5. Dilatation of a partially occluded ureter is a rare finding. The 
corresponding kidney becomes atrophied and cystic unless there is 
an additional outlet to the urine. 

6. Bending and twisting of the ureter is associated with hydro- 
nephrosis, which, in time, may result in complete cystic degenera- 
tion of the kidney. 

INFLAMMATION OF THE URETER. 

Ureteritis rarely exists apart from a similar involvement of the 
bladder or kidney, and is usually secondary to these lesions. 
The causes of ureteritis are : 

1. Extension downward from the kidney. 

2. Extension upward from the bladder. 

3. Foreign bodies lying within the ureter. 

Tuberculous urethritis is most often primary in the kidney, ex- 
tending downward to the ureter and finally involving the bladder 
and urethra. 

The streptococcus, staphylococcus, and gonococcus infections 
almost invariably begin in the urethra or bladder and extend up- 
ward to the ureter and kidney. 

It is a matter of common observation that an infection may be 
conveyed from the bladder to the kidney without leaving an evi- 
dent lesion in the ureters, and it is also observed that the secretions 
from the infected kidney may continuously bathe the mucosa of 
the ureters without infecting them, and yet infect the bladder. 

The diagnosis of ureteritis as an independent lesion is seldom 
made ; the clinical picture is usually involved in a cystitis or 
pyelonephritis. 



460 DIAGNOSIS OF DISEASES OF THE URINARY SYSTEM. 

Pain and tenderness along the course of the ureter are the most 
characteristic clinical manifestations of ureteritis. 

It is possible to outline the pelvic portion of the thickened, 
tender ureter by a vaginal examination. The fingers introduced to 
the anterolateral wall of the vagina will follow the cord as it passes 
to the vault of the vagina and on to the side of the cervix. It 
must not be mistaken for a thickened adherent tube or ovary. 
Through the rectum the ureter may be traced to a higher level. 

Tenderness on pressure will serve as a guide to the course of the 
ureter through the abdomen. 

In a cystoscopic examination the ureteral prominence is seen to 
be injected with bloodvessels radiating from the ureteral orifice. 
Cloudy and purulent urine may be seen to drip from the orifice 
into the bladder. 

A ureteral catheter will serve to collect the urine from the affected 
ureter, and this can be compared with the urine from the other 
ureter. 

Tuberculous ureteritis is almost never a primary infection, but is 
usually secondary to tuberculous pyelonephritis. 

We may speak of an ascending tuberculous infection, when the 
ureter is involved secondary to the bladder ; of a descending tuber- 
culous infection, when the kidney is primarily infected. The infec- 
tion may descend on one side and subsequently ascend on the other 
side. 

The walls of the ureter are greatly thickened and the lumen is 
narrowed from thickening and caseous degeneration of the mucosa. 
Healing of ulcerated surfaces may result in a cicatricial contraction 
and obliteration of the lumen ; the ureter may be further obstructed 
by a plug of caseous material. This obstruction leads to hydro- 
nephrosis, and, finally, to cystic degeneration of the kidneys. A 
tuberculous pyonephrosis will almost inevitably result from such 
obstruction. 

In advanced cases blood is found in the urine. Pus is invariably 
present in the urine, and in it tubercle bacilli are occasionally 
found. A positive clinical diagnosis can only be made by finding 
the tubercle bacillus in the urine catheterized from the ureters. 
When found in the presence of a thickened, tender ureter, the diag- 
nosis of tuberculous urethritis is established. 

The smegma bacillus closely simulates the tubercle bacillus in its 
size, form, and staining qualities. It is found in the secretions of 



THE DIAGNOSIS OF THE DISEASES OF THE URETERS. 461 

the external genitals, and is not to be confounded with the tubercle 
bacillus. In a catheterized specimen no smegma bacilli will be 
found. 

Inoculation experiments may be carried out on guinea-pigs and 
rabbits with promising results. Injections with tuberculin as a 
diagnostic measure have been made, with positive results. 

The finding of tuberculosis in the bladder or kidney, associated 
with an irregularly thickened, tender cord, should establish the 
diagnosis of the tuberculous ureteritis to a high degree of probability. 

OBSTRUCTION OF THE URETER. 

The ureter is more frequently obstructed in women than in men — 
a fact to be explained by the pressure exerted upon the ureter by 
swellings of the uterus, tubes, and ovaries. 

Causes. The following classification is from Kelly : 
First, causes acting from ivithout and occluding the ureter by press- 
ing upon it, such as : 

1. Ovarian tumors. 

2. Uterine tumors. 

3. Cancerous infiltration of the broad ligaments. 

4. Cancer of the caecum. 

5. Retroperitoneal pelvic sarcoma. 

6. Aneurism of the iliac artery. 

7. Scar tissue in the broad ligament. 

8. Perineuritis. 

9. An omental adhesion to the pelvic brim. 

10. Thickened bladder walls. 

11. Sarcoma of the bladder. 

12. Pedunculated tumor of the bladder. 
Second, foreign bodies lodged in the ureteral canal: 

1. Calculus. 

2. Blood clot. 

3. Echinococcus cyst. 

Third, affections of the ureteral walls themselves : 

1. Ureteritis bacilli coli communis. 

2. Ureteritis gonorrhoeica. 

3. Ureteritis tuberculosa. 

4. Valve formation in the ureteral wall. 

5. Gumma in the wall. 



462 DIAGNOSIS OF DISEASES OF THE URINARY SYSTEM. 

6. Cancer of the ureter. 

7. Psorospermial cysts. 

The point of obstruction is most frequent in the pelvic portion 
of the ureter. Here the ureter is often engaged between the 
unyielding bony wall of the pelvis and various tumors and inflam- 
matory swellings within the pelvis. One or both ureters may be 
involved. 

The diagnosis involves not only the fact of obstruction to the 
ureter, but the determination of the cause of the obstruction, its 
location, the rapidity with which it has developed, and the extent 
of the obstruction. 

The clinical manifestations are variable and unreliable. Pain in 
the region of the kidney and ureter is the most constant symptom, 
yet a moderate degree of obstruction may exist without causing 
symptoms. The more rapidly the obstruction develops the greater 
are the clinical disturbances. 

Frequent painful urination suggests an inflammatory obstruction 
or a calculus. Symptoms are particularly unreliable as a guide to 
the diagnosis in a slowly developing obstruction. Where the ureter 
has been suddenly plugged with a calculus or blood clot, the inten- 
sity and location of the pain are so characteristic as to frequently 
serve for a diagnosis. 

In making a diagnosis of obstruction of the ureter all causes 
above enumerated are to be sought for. All swellings of the pelvis 
are to be outlined in a bimanual examination. Where there is 
frequent, painful urination and the cause of the disorder cannot be 
located in the ureter or bladder, it becomes imperative to explore 
the ureters by bougies and catheter. An inflammatory swelling of 
the ureter palpated through the vaginal wall suggests a probable 
cause for the obstruction, but does not eliminate the possible 
existence of other causes. 

The only positive means of locating an obstruction in the ureter 
is by the passage of a bougie or catheter. The instrument will 
meet with an obstruction at a point below the pelvis of the kidney, 
or after passing a given point with some resistance the constricted 
portion grasps the instrument so as to resist its withdrawal. Occa- 
sionally when passing a ureteral catheter no special resistance will 
be noticed until there appears a sudden discharge of an unusual 
amount of fluid which has accumulated behind the obstruction. 



THE DIAGNOSIS OF THE DISEASES OF THE URETERS. 463 

URETERAL CALCULUS. 

Calculi may lodge at any point in the course of the ureter, but 
are most often found near the pelvis of the kidney, the floor of the 
pelvis, and the flexure at the pelvic brim. These calculi are 
elongated and cone-shaped. They are of rare occurrence. 

The diagnosis is based upon the periodic recurrence of a colicky 
pain radiating from the kidney along the course of the ureter. 
Following these attacks of pain there may be a rise of temperature 
and the appearance of blood in the urine. 

Occasionally the stone will act as a ball-valve in plugging the 
ureteral opening of the pelvis of the kidney. In such an event 
there will be a temporary hydronephrosis with intermittent dis- 
charge of the contents through the ureter. Under favorable condi- 
tions a stone may be palpated through the vaginal wall. In rare 
instances a stone has been seen through a cystoscope to project from 
the ureter into the bladder. 

When the stone lies higher up in the ureter it is detected with 
absolute certainty by passing a catheter or sound. The device 
practised by Howard Kelly of tipping the catheter or sound with 
wax is of special service in these cases. 

STRICTURE OF THE URETER. 

Direct violence is seldom the cause of stricture of the ureter 
because of its deep-seated position. The passage of a stone may 
result in a stricture, as may also long-standing inflammatory lesions 
in and about the ureter. 

HYDROURETER AND HYDRONEPHROSIS 

develop when the passage of the urine is obstructed. Pyoureter 
and pyonephrosis may develop secondary to an obstruction in the 
ureter and are dependent upon a pyogenic infection. These con- 
ditions are diagnosed by the passage of a catheter beyond the point 
of obstruction and the emptying of the accumulated fluid. Abdom- 
inal palpation may detect a cystic swelling. Continuous pain or 
intermittent colic in the region of the kidney and ureter are highly 
suggestive of the condition, though no positive diagnosis can be 
made without an exploratory puncture through an incision in the 
back or catheterization of the ureter. 



464 DIAGNOSIS OF DISEASES OF THE URINARY SYSTEM. 

URETERAL FISTULA. 

A fistulous communication may be established between the ureter 
and the abdominal wall or some part of the genital or alimentary 
tract. Part or all of the urine may be directed into these structures. 

The majority of ureteral fistulse are caused by direct injury in 
vaginal and abdominal operations and in labor. Other causes are 
ulcerations following tuberculosis, carcinoma, and foreign bodies of 
the ureter. Rarely are the fistulse congenital. 

The diagnosis does not involve great difficulties. When but a 
single ureter is involved the urine is being constantly lost, while at 
the same time the bladder is filled and emptied at natural intervals. 
Were there present a vesicovaginal or vesicouterine fistula, such an 
event would be impossible. A colored sterile fluid (milk, perman- 
ganate of potassium) may be injected into the bladder, and if the 
urine continues to return clear no vesicovaginal fistula is present ; 
the fistula must necessarily be ureteral. 

Positive evidence is obtained by exposing the ureteral opening 
by means of a cystoscope and passing a sound or catheter into the 
ureter. 



PLATE XL1V. 




Situation of the viscera. 



Outlines of heart and vessels— broad red lines. Margins of lungs and individual lobes— dotted 
green lines. Limits of pleural sacs— solid green lines. Liver — red shading. Stomach— green 
shading. (In part after His-Spalteholz and Luschka. 



PLATE XLV. 



Fig. 1. 



,' • i 



*_^_— -s^9*! 





M A 



V) 



Movable kidney. 

Fig. 2. 




rrf ^m 






Sarcoma of the right kidney. 



CHAPTER XXXIV. 

THE DIAGNOSIS OF THE DISEASES OF THE KIDNEY. 

Topography of the Kidneys. The kidneys are located in the 
lumbar region. They usually extend from the twelfth dorsal to 
the third lumbar vertebra ; the left lies at a little higher level than 
the right. 

Methods of Examination. Palpation of the normal kidney is 
possible under favorable conditions. With the fingers of one hand 
supporting the lumbar muscles, and those of the other hand pressing 
deeply into the lumbar region from the front immediately below 
the costal arch, the abdominal muscles being thin and relaxed, the 
normal kidney may be felt. 

When the kidney is enlarged or displaced palpation is usually not 
difficult. 

A kidney that cannot be palpated with the patient in a recum- 
bent position may be felt with ease by directing the patient to stand 
on her feet while supporting her body by her hands upon the seat 
of a chair. In this manner the abdominal walls are relaxed and 
the kidney falls downward and forward. It is important to observe 
the respiratory movements of the kidney. 

Percussion of the normal kidney is very difficult because of its 
deep-seated position. 

MOVABLE KIDNEY. 

Under normal conditions the kidney is firmly embedded in fat, 
and is supported by the fat, the overlying peritoneum, and the 
renal bloodvessels. 

A movable kidney may be a congenital lesion, but is almost 
invariably acquired. Kiittner collected 667 cases, of which 584 
were in women and 83 in men. The same author observed the 
right kidney movable in 553 cases, the left in 81, and both in 93. 
According to Edebohls, about 20 per cent, of gynecological cases 
have a movable kidney. Tight lacing and pregnancy account for 

30 



466 DIAGNOSIS OF DISEASES OF THE URINARY SYSTEM. 

the greater frequency in women. Other exciting causes are heavy 
lifting, absorption of the perirenal fat, and an enlarged liver or 
spleen crowding the kidney out of place. 

Three degrees of mobility are recognized : the palpable kidney, 
when the range of motion is limited, yet the kidney can be pal- 
pated ; movable kidney, when the range of motion is not below the 
level of the umbilicus, and floating kidney, when the kidney can be 
moved beyond the median line of the abdomen and below the level 
of the umbilicus. It is possible for the kidney to be at the brim 
of the pelvis. 

The diagnosis is seldom difficult. The shape, consistency, posi- 
tion, and mobility of the kidney will usually suffice for a diagnosis. 
In very many cases there are no symptoms. A very movable 
kidney may give rise to no symptoms, while one with a limited range 
of motion may cause serious disturbances. A sense of dragging 
and discomfort in the side is the usual complaint. Various hysteri- 
cal manifestations and gastric disturbances are chargeable to a 
movable kidney. Frequent painful urination is an occasional com- 
plaint. 

DieWs crisis is characterized by chills, fever, nausea, vomiting, 
severe abdominal pain, and collapse. The explanation for the 
paroxysms is not clear. Dietl believes them due to a kinking of 
the bloodvessels and ureter. 

The abdominal walls are usually relaxed, and there is frequently 
a general visceraoptosis. 

The kidney is identified by its bean-shape, general outline, con- 
sistency, and mobility, and by the fact that it can be replaced. 
The most common location is the midclavicular line just above the 
level of the umbilicus. 

Movable kidney is to be differentiated from a distended gall- 
bladder and tumors of the pylorus and pelvis. 

Distention of the gall-bladder is recognized by the clinical mani- 
festations of a disease of the gall-ducts and by a lesser degree of 
mobility than is common to a movable kidney. A distended gall- 
bladder cannot be pushed downward. It remains in close proximity 
to the abdominal wall whatever the position of the patient, while 
a movable kidney changes with the change of position of the patient. 
It may be possible to feel the kidney in its normal position behind 
the distended gall-bladder. 

Cancer of the pylorus is associated with the general signs of 



THE DIAGNOSIS OF DISEASES OF THE KIDNEY. 467 

malignancy, dilatation of the stomach, and vomiting. The kidney 
may be palpated distinct from the tumor mass. 



ENLARGEMENT OF THE KIDNEY. 

The lesions tending to enlarge the kidney are hydronephrosis, 
pyonephrosis, abscess, perinephric abscess, and new formations. 
Such enlargements may be detected by palpation and percussion. 
Comparison of the two kidneys will be of value in estimating the 
increase of size. 

Hydronephrosis consists in a distention of the pelvis of the kidney 
with urine, and is caused by an obstruction of the ureter (see 
page 461). It is rarely congenital. The most frequent causes are 
renal calculi, pressure from surrounding tumors, and kinking of 
the ureter in a movable kidney. Malignant and inflammatory 
lesions in the bladder may obstruct the ureteral opening. The heal- 
ing of ulcers in the ureter and about the ureteral prominence in 
the bladder is known to obliterate the lumen of the ureter. 

Whatever the cause of obstruction to the urine in the ureter, 
there is an accumulation of urine in the pelvis and infundibulum. 
As the tension increases the papillae atrophy, and, finally, the kid- 
ney becomes almost completely atrophied and replaced by cystic 
spaces. 

However great the distention, there is nearly always some renal 
tissue to be found. 

A strange observation is that hydronephrosis is most extreme 
where the obstruction is not complete and where the urine is dis- 
charged intermittently. Where the obstruction is complete the 
kidney usually atrophies and hydronephrosis may not develop. 
The distention may be enormous, filling the entire abdomen ; this 
distention suggests the presence of an ascitic accumulation or an 
ovarian cyst. 

The diagnosis is based wholly upon the physical findings. No 
symptoms may be present. When unilateral and of moderate size 
no serious difficulty is experienced. 

On physical examination a tumor occupies the renal region. 
When in doubt as to the nature of the swelling, it should be 
aspirated. The fluid of hydronephrosis is clear or turbid, and 
there are present urea, uric acid, and some albumin. In cases of 
long standing the urinary elements may disappear, so that aspiration 



468 DIAGNOSIS OF DISEASES OF THE URINARY SYSTEM. 

can no more than identity the tumor as cystic. Nothing can be told 
of its origin from the aspirated fluid. 

Intermittent hydronephrosis is sometimes associated with a 
movable kidney, and is explained in such cases by the occasional 
kinking of the ureter. The pelvis of the kidney distends and 
discharges at intervals, to again refill. 

It is possible for the fluid to be evacuated and never refill. Sup- 
puration may follow, converting a hydronephrosis into a pyoneph- 
rosis. 

Pyonephrosis (pyelitis). A purulent secretion collects in the 
pelvis of the kidney. The suppurative process may extend to the 
kidney substance, giving rise to a pyelonephritis. The kidney 
substance atrophies, and little other than the capsule may remain 
to form the abscess sac. The lesion may involve one or both 
kidneys. 

The causes of pyonephrosis are renal calculi, tuberculosis, acute 
and chronic infectious diseases, decomposed urine in a hydroneph- 
rosis, cystitis from various causes, and, finally, movable kidney. 

Pyogenic organisms are essential to the development of pyo- 
nephrosis. These micro-organisms are chiefly the streptococcus 
pyogenes, staphylococcus pyogenes albus and aureus, colon bacillus, 
gonococcus, and tubercle bacillus. 

The diagnosis is based upon the subjective symptoms of infection, 
upon the local findings in an external examination, catheterization 
of the ureters, and urinalysis. Chills, sweating, and an irregular 
fever may indicate a pus infection. The pain in the renal region 
would suggest the site of the infection. The patient becomes 
ansemic and loses flesh. A tumor mass is felt in one or both 
sides, which is tender to pressure and may assume large propor- 
tions. 

The size of the tumor varies from time to time, and is in inverse 
proportion to the discharge of pus in the urine. 

The urine always contains pus, usually casts and sometimes 
bits of renal tissue. It is acid in reaction unless decomposition 
takes place in the bladder. A positive diagnosis is made by an 
exploratory puncture or incision through the back or by a cysto- 
scopic examination and catheterization of the ureter and pelvis. It 
is not only possible to withdraw the pus from the pelvis, but perma- 
nent cures have been effected by irrigating the pelvis of the kidney 
through a ureteral catheter. 



THE DIAGNOSIS OF DISEASES OF THE KIDNEY. 469 

By catheterizing the ureters it is possible to positively demon- 
strate the involved kidney and to exclude cystitis and ureteritis. 

A bacteriological examination of the pus should be made. The 
presence of tubercle bacilli will identify a tuberculous pyonephrosis. 

PERINEPHRIC ABSCESS. 

An abscess about the kidney usually develops secondary to a 
pyonephrosis, but may be primary as a complication of infectious 
diseases and as a result of exposure to cold and direct injury. 

The general symptoms are not unlike those of pyonephrosis. A 
swelling appears in the lumbar region which is at first hard and 
later fluctuating. The overlying skin is oedematous. The swell- 
ing is tender to pressure, and pain may radiate from the swelling 
to the thigh. 

When the kidney is not involved there will be no pus in the 
urine. The two conditions likely to be confounded with a peri- 
nephritic abscess are coxitis and appendicitis. In the former are 
evidences of tuberculous infection in the vertebrae and possibly else- 
where ; in the latter is the history of a previous attack of appendicitis 
with its intestinal disturbances. It must be remembered that pus 
arising from either a coxitis or appendicitis may accumulate about 
the kidney. 

NEW FORMATIONS OF THE KIDNEY. 

Tumors of the kidney are benign or malignant. The benign 
tumors are fibroma, lipoma, angioma, lymphadenoma, aberrant 
adrenals, and adenoma. All these are exceedingly rare, with the 
exception of fibromata, which are frequently found as small nodules 
in the pyramids. 

The malignant tumors are sarcoma, carcinoma, and hyper- 
nephroma. 

Sarcoma is the most common of the new formations of the kid- 
ney. The growth may occur at any age, but it is peculiarly likely 
to appear in childhood. It is known to be congenital. Dr. 
William Roberts found twenty-five out of twenty- seven cases in 
children under ten years. They usually assume the alveolar form. 

Carcinoma is less frequent, and is of the encephaloid variety. 
Both carcinoma and sarcoma may grow to an enormous size. Morris 
reported a sarcoma of the kidney weighing thirty-one pounds. 



470 DIAGNOSIS OF DISEASES OF THE URINARY SYSTEM. 

Their growth is rapid. In older individuals they are frequently 
preceded by calculus of the kidney. 



HYPERNEPHROMA 

has been imperfectly understood until recently. Formerly it was 
confounded with carcinoma, sarcoma, endothelioma, adenoma, 
lipoma, and angioma. Grawitz, in 1883, asserted that these rare 
tumors originate from adrenal tissue misplaced in the kidney sub- 
stance during the process of development. 

The growth is very soft, rarely invading the kidney, and is 
enveloped in a capsule. Hemorrhagic areas and cystic spaces are 
common. Metastasis to the lungs, liver, and bones are occasionally 
observed. Their growth is very rapid, and they are known to 
attain a large size. They are rarely seen in early life ; the time of 
election is between forty and fifty years of age. A beautiful illus- 
tration of a hypernephroma is seen in an article by C. P. Noble 
and W. W. Babcock in the July, 1902, number of the American 
Gynecology. 

The diagnosis of malignant tumors of the kidney is based upon 
the appearance of blood in the urine, renal colic, general evidence 
of malignancy, and the local signs of a rapidly growing tumor of 
the kidney. 

Hematuria may be the first indication. The blood in the urine 
may be fluid, but sometimes appears as casts of the ureter and pelvis 
of the kidney. Osier says he has never seen these casts in the 
urine except in cancer of the kidney. There is usually no blood in 
the urine in hypernephroma, because the tumor rarely invades the 
kidney substance. 

Pain is not always present even in large tumors. It is located 
in the lumbar region and radiates down to the thigh and urethra. 
Colicky pain may be caused by clogging of the ureter with blood 
clots. 

The general evidences of malignancy are emaciation and cachexia. 
The symptoms usually develop rapidly, though at times are very 
late in making their appearance. 

A large abdominal tumor in an infant is either a sarcoma of the 
kidney or a retroperitoneal sarcoma of the lymph glands. The 
tumor is small or nodular, and is usually firmly fixed. The descend- 
ing or ascending colon lies in front of the growth unless its enormous 



THE DIAGNOSIS OF DISEASES OF THE KIDNEY. 471 

size crowds the colon to one side. The soft, elastic character of 
the tumor may be mistaken for fluctuation. The percussion note 
is dull except in front, where the tumor is covered with the inflated 
colon. 

The movable renal tumor may be confounded with a tumor of 
the ovary or a pedunculated fibroid of the uterus. A pelvic exam- 
ination will demonstrate the connection of pelvic tumors with the 
uterus. 

Enlargements of the liver and spleen are recognized by their out- 
line, their immediate contact with the abdominal wall, the colon 
lying behind the swelling, and the absence of blood in the urine. 

CYSTIC KIDNEYS. 

Cystic spaces may occupy the kidney as a congenital or acquired 
defect. Any obstruction to the outlet of the urine may lead to 
hydronephrosis with cystic degeneration of the kidney. Echino- 
coccus cysts of the kidney have been described. 

RENAL CALCULI. 

Kidney stones are formed by the deposition and agglutination of 
the normal and abnormal salts found in the urine. 

The conditions predisposing to precipitation of the urine and the 
formation of stone are decomposition of the urine, supersaturation 
of the urine with salts, and the presence of abnormal constituents 
in the urine. It has been repeatedly emphasized that renal calculi 
very frequently form about a nucleus of desquamated epithelium, 
micro-organisms, and blood-coagulum. Harris has recently demon- 
strated the important role of micro-organisms in the formation of 
renal calculi. He substantiates his statement by the following 
facts : " Precipitation alone does not cause stone. Foreign bodies, 
such as exfoliated epithelial cells, blood clots, or those introduced 
experimentally from without, do not cause stone so long as they 
remain free from microbes. The kidneys frequently eliminate 
microbes with the urine without themselves becoming the seat of 
microbic invasion. These microbes may develop in the urine in 
the pelvis and cause the precipitation of certain salts. The char- 
acter of the precipitate depends not entirely upon the composition 
of the urine, but also upon the kind of microbe present. The 
microbes in developing form zoogloea masses, in and about which the 



472 DIAGNOSIS OF DISEASES OF THE URINARY SYSTEM. 

precipitate takes place. The agglutination of the particles by the 
zoogloea mass forms the nucleus or starting-point of the stone. 
Such zoogloea masses have been formed clinically in the urine. 
The microbe found most frequently in the urine is the colon 
bacillus. It grows in acid urine and under proper conditions causes 
precipitation of uric acid and acid urates. Microbes have been 
found in the centre of so-called primary stones. From the clinical 
side we find stones frequently preceded by a history of acute or 
chronic intestinal disorders ; of suppurative lesions of the skin ; of 
acute infectious diseases, as influenza, pneumonia, typhoid fever. 
Women very commonly date the beginning of their trouble from 
a confinement or imperfect puerperium. These conditions are all 
such as readily account for the presence of microbes in the urine." 
From these facts Harris is led to believe that almost all renal 
stones are of microbic origin. 

Certain chemical forms of calculi are recognized. These are : 

1. Uric acid calculi, which are the most common form, and range 
in size from sand-like particles to stones the size of a man's fist. 

2. Oxalate of lime calculi, which take the form of a mulberry and 
rarely attain large proportions. 

3. Phosphatic calculi, composed of the triple phosphates. They 
are not common as compared with stones of similar composition in 
the bladder. 

4. Cystine, xanthine, indigo, and carbonate of lime which very 
rarely form renal calculi. 

Renal calculi may be passed with little discomfort, and may 
remain in the kidney without the knowledge of the patient. The 
passage of a single stone may end the difficulty or repeated attacks 
of colic may be followed by the passage of a great number of stones. 
So long as the stone remains buried in the kidney substance there 
will be no renal colic ; but when it engages in the ureter and 
will not readily pass, a cramping, lancinating pain radiates down- 
ward from the kidney. Nausea and vomiting may accompany these 
attacks of renal colic, a chill may precede the outbreak, and the 
temperature often rises to 103° F. An initial chill may precede 
the attack. The following quotation is from Montaigue, who 
suffered for years from stone in the kidney : " Thou art seen to 
sweat with pain, to look pale and red, to tremble, to vomit well- 
nigh to blood, to suffer strange contortions and convulsions, by 
starts to let tears drop from thine eyes, to urine thick, black, and 



THE DIAGNOSIS OF DISEASES OF THE KIDNEY. 473 

frightful water, or to have it suppressed by some sharp and craggy 
stone that cruelly pricks and tears thee." 

The pain may be referred to the opposite kidney. The blood in 
the urine is seldom excessive, and may appear only after exertion. 
As a rule, it no more than makes the urine smoky. Pyelitis may 
develop. This is ushered in by a chill and rise of temperature, 
pain and tenderness will be more or less constant in the region of 
the kidney, and pus will appear in the urine. 

From the above clinical manifestations a diagnosis may often be 
established to a high degree of certainty. A positive diagnosis is 
made by the X-ray, and occasionally by sounding the pelvis of the 
kidney with a wax-tipped ureteral bougie or catheter. 

Renal colic may be confounded with hepatic and intestinal colic. 
The location of the pain, its disposition to radiate to the end of the 
urethra, the appearance of the urine, the X-ray, and, finally, the 
sounding of the ureter and pelvis will determine the diagnosis. 
A renal calculus is distinguished from stone in the bladder by a 
cystoscopic exauiination and by the sound. 



CHAPTER XXXV. 

THE .DIAGNOSIS OF THE CAUSES OF TOO FREQUENT AND 
PAINFUL MICTURITION. 

Almost all conditions which cause pain in urinating also cause 
frequent urination. The two disorders are therefore best considered 
together. A distinction is clearly made between too frequent urina- 
tion and incontinence of urine. The former implies an ability to 
retain the urine for a limited time, while in the latter condition the 
urine is voided as fast as it enters the bladder. 

Either of these disorders may be congenital or acquired. They 
may be continuous or interrupted by intervals of complete relief. 

Causes. 1. Pregnancy. During the first trimester and in the 
last month of pregnancy the patient urinates more frequently, though 
seldom with pain. The explanation lies in the position of the 
enlarged uterus. 

2. Nervous diseases, both functional and organic. Pain is rarely 
present. A hypersesthetic condition of the bladder is the expla- 
nation. 

Nocturnal enuresis is a functional disorder attributable to an irri- 
table spinal centre. The urinary organs are in a normal state. 
The condition rarely lasts after puberty. 

3. Hypersecretion of urine, as in diabetes and hysteria, will 
demand frequent evacuation of the bladder. 

4. Overdistention of the bladder from an atonic condition of the 
bladder wall or obstruction to the outflow of urine as from stricture 
may cause a frequent desire to urinate and the voiding of but a 
small quantity of urine. That which is voided is merely the over- 
flow. Following upon an overdistention of the bladder there may 
be a frequent desire to urinate due to the irritation of the bladder 
and sphincter urethrae. In young women who through false 
modesty urinate at long intervals the inability to long retain the 
urine is frequently acquired. Such a condition may be incurable. 
The author recalls the case of a young woman who habitually 
retained her urine for twenty-four hours, and gave as her reason that 



CAUSES OF FREQUENT AND PAINFUL MICTURITION 475 

she did not like to go to stool. Such practices cannot fail to result 
disastrously. 

5. Displacements of the uterus and the encroachment of pelvic 
tumors and exudates not seldom cause a frequent desire to urin- 
ate, and if these encroaching structures are tender to pressure 
urination will be painful. In forward displacements of the uterus 
the fundus presses upon the bladder and lessens its capacity. In 
retroversion of the uterus the cervix may cause frequent urination 
by impinging against the urethra and base of the bladder. One of 
the earliest evidences of cancerous invasion of the bladder from the 
cervix is frequent, painful urination, together with the appearance 
of blood in the urine. 

6. Dislocation and diseases of the urethra tend to cause frequent 
and, many of them, painful urination. The reader is referred to the 
discussion of these subjects. 

7. All inflammatory diseases and new formations of the bladder, 
ureters, and kidneys cause frequent and often painful urination. 

The new-growth which causes most intense pain in urinating and 
is the most frequent cause of painful urination is caruncle. The 
pain thus caused is described as " shooting," " cutting," and 
" scalding." 

8. Foreign bodies, notably stone, in any portion of the urinary 
tract cause frequent painful urination. 

9. Highly concentrated urine may cause frequent and slightly 
painful urination ; these symptoms disappear upon drinking large 
quantities of water. 



CHAPTER XXXYI. 

THE DIAGNOSIS OF THE CAUSES OF INCONTINENCE AND 
RETENTION OF UEINE. 

1. Incontinence of Urine. No urine is retained in the bladder, 
but escapes as fast as it is conveyed through the ureters. This dis- 
order may be congenital or acquired. As a congenital lesion we 
find defect in the development of the urethra and bladder. The 
bladder may be congenitally small, or there may be a lack of devel- 
opment in the sphincter urethrse. 

Acquired incontinence is most often due to fistulse leading from 
some portion of the urinary tract to the exterior by way of the 
vagina, cervix, uterine body, bowel, or abdominal wall. 

Overstretching of the urethra in the passage of instruments and 
the finger into the bladder may result in temporary and sometimes 
permanent incontinence of urine. 

As a complication of many of the nervous disorders incontinence 
of the urine is frequently observed. 

II. Retention of Urine. 1. Hysteria as a cause of retention of 
urine is little recognized. Too often the catheter is inserted with- 
out recognizing the hysterical element in the case. Tabes dorsalis 
is often associated with retention of the urine. 

2. Pressure upon the urethra, bladder, and ureters by a displaced 
uterus and by new formations and inflammatory exudates in the 
pelvis and abdomen. 

The cervix in a retroversion, and especially when the uterine 
body is enlarged through pregnancy or tumor formation, may press 
upon the urethra and obstruct the passage of the urine. 

New-growths, particularly fibroids of the uterus, occasionally 
compress the urethra and cause retention of the urine. 

3. Obstruction of the urethra, bladder, and ureters by new-growths 
and calculi occupying the interior of these structures. 

4. Spasmodic retention due to a spasm of the urethra. This 
disorder is much rarer in women than in men. It has been 
improperly called a spasmodic stricture. 

5. Atony of the bladder due to overdistention and as a complica- 
tion of certain nervous and wasting diseases. 



INDEX OF AUTHORS 



Abel, 298, 365 

^Etius von Ameda, 142, 409 

Bandl, 403 

Bandler, 366, 367 

Baumgart, 144 

Baumgarten, 357 

Bayea, 297 

Bebkiser, 295 

Beckmann, 187 

Benoit, 334 

Birch-Hirschfeld, 243 

Bloom, Agnes, 216 

Bowen, 203 

Bowin, 142 

Bouchard, 334 

Boucher, 450 

Braiin, 439 

Bulius, 356 

Casper, 415 

Charries, 321 

Chiari, 206, 243, 316, 320 

Chrobak, 371 

Cohnheim, 306 

Coupland, 364 

Croom, 126 

Cullen, 92, 265, 288, 295 

Cullingworth, 137 

Cushing, 394 

Davidson, 230 

Dechamps, 206 

Deciderius, 369 

Demure, 206 

Dietrich, 31 

Doderlein, 244 

Donhoff, 330, 334 

Doran, 335, 358 

Downes, 430 

Dudley, E. C, 163 

Dudley, Palmer, 345 

Duges, 203 

Duncan, Matthews, 235 

Edebohls, 465 

Ellinger, 79 

Engelmann, 24 

Engstrom, 256 

Eppinger, 243 

Everett, 267 

Farre, 338 

Fehling, 263 

Fisher, 215 



Fraenkel, 144, 148, 160 
Frank, 357 
Freund, 172 
Friedlander, 227 
Fritsch, 143, 410 
Frommel, 321 

- Gebhard, 26, 226, 244, 264, 266, 294, 295 
Gottschalk, 157, 257, 264 
Graham, D. W., 279 
Granger, 334 
Grawitz, 470 
Guillemain, 356 
: Gurlt, 306 
Gusserow, 306 
Guthrie, 313 
Hammerstan, 362 
Harris, M. L., 430, 471, 472 
Hart, Berry, 152, 264, 306 
Hegar, 78, 350, 377 
Herman, 31, 244 
Hertz, 264 
Herxheimer, 31, 32 
Herzog ; 28 
Hippocrates, 142, 267 
Hofmeier, 295 
Homans, 358, 370 
Hugenberger, 440 
Irion, 24 

von Kahlden, 31, 32 
Kaltenbach, 144 
Kaufman, 295 
Kehrer, 187 

Kelly, 256, 409, 412, 415, 417, 418, 421, 
424, 442, 446, 455, 456, 457, 461, 463 
Klebs, 243 
Klein, 234, 440 
Kleinwachter, 257 
Klobs, 256, 350 
Kossman, 142, 264 
Koster, 148 
Kreutzmann, 148 
Krussen, 329 
Korzysz-Kowski, 151 
Kuhn, 130 
Kundrat, 26, 330 
Kiister, 31, 203 
I Kuttner, 465 
Kworostansky, 152 
Ladinski, 154 
Landau, 244 



478 



INDEX OF A UTHORS. 



Landel, 243 

Lecorche, 357 

Le Count, 244, 335 

Leopold, 39, 280, 361, 371 

Lepine, 334 

Lorey, 264 

Majer, 143 

Marchand, 144, 148, 149, 160, 371 

Martin, 31, 314, 321, 329, 330, 341, 343, 

346, 356, 358, 364 
Menge, 206, 295, 351, 357, 394 
Meyer, W., 330 
Moricke, 26 
Morris, 469 
Mosler, 357 

Mueller, 215, 220, 230, 256 
Muer, 334 
Nagel, 205 

Neumann, 148, 151, 153, 156 
Nitze, 409, 415, 417, 418 
Nobel, 265 
Noeggerath, 313 
Ochsner, 329 
Olshausen, 188, 239, 244, 358, 359, 365, 

391 
Orth, 243, 346, 370 
Orthmann, 369 
Pagel, 450 
Palmer, 80 
Pantz, 154 

Pawlik, 409, 415, 417, 418, 421, 455 
Peckham, 213 
Peters, 149, 160 
Petrow, 243 

Pfannenstiel, 307, 346, 359, 370 
Philips, 439 
Pick, 152, 278, 295, 370 
Pierce, Frank, 234 
Ponfick, 243 
Popoff, 31, 32, 350 
Poten, 152, 155, 156 
Pozzi, 244, 335 
Preuschen, 230 
Prochowick, 321 
Pryor, 455 
Quain, 341 

Kecklinghausen, 264, 335 
Reed, 197 
Reinecke, 31 
Richet, 357 
Richie, 335 
Ries, 295 
Rindfleisch, 243 
Robb, Hunter, 215 
Roberts, William, 469 
Rosger, 257 
Rosthorn, 330 



Ruge, 244, 249, 250, 264, 279 

Rumler, 148 

Runge, 144 

Russel, 371 

Sanger, 160, 218, 334, 335, 336, 341 

Schatz, 346, 350 

Schauta, 316, 320, 321 

Schmidt, 50, 234 

Schroeder, 142, 198, 394 

Schramm, 330 

Schwarz, 214, 215 

Shenck, 371 

Shultze, 172, 196, 236, 346 

Simon, 415, 429 

Simpson, Sir James Y., 82 

Skene, 410 

Smith, Richard R., 231 

Spencer, 359 

Spiegelberg, 303 

Stewart, 334 

S torch, 147 

Stratz, 350 

Suchanek, 434 

Sutton, Bland, 317, 335, 356, 364, 372 

Tait, Lawson, 383 

Tamesvary, 370, 371 

Thoma, 243 

Thornton, 386 

Ulmann, 341 

Van der Hoeven, 143, 148, 151 

Van Heukelom, 243 

Vassmer, 152 

Vedeler, 257 

Veit, 152, 250 

Velpeau, 142 

Virchow, 142, 144, 147, 258, 439, 445 

Voigt, 157 

Waldeyer, 338, 359 

Webster, J. C, 27, 122, 126, 147, 148, 

152, 178, 179, 215, 218, 288 
Weichselbaum, 243 
Welsh, 280 

Wenkel, 206, 214, 220, 330, 341, 409, 440 
Wenkler, 295 
Werth, 295 

Wertheim, 313, 321, 394 
Westphalen, 26 
Williams, Bristol, 231 
Williams, Roger, 306 
W T illiams, Whitridge, 26, 233, 256, 306, 

334, 350, 357 
Winter, 114, 296,^374 
Wolf, 356 
Zangemeister, 370 
Zeller, 295 
Zemann, 334 
Ziegler, 350 



INDEX 



ABDOMEN, auscultation of, 56 
in ectopic pregnancy, 133 
in pregnancy, 109. 
inspection of, 51 
mensuration of, 56 
palpation of, 52 

in ectopic pregnancy, 133 
percussion of, 55 
Abdominal examination, external, 51 

wall, phantom tumors of, 378 
Ab domino-vaginal examination, 62 
Abdomino-vagino-rectal examination, 

69 
Abortion, diagnosis of, 115 

tubal, 127 _ 
Abscess formation in tubal pregnancy, 
128 
of ovary, 351, 353 
pericecal, 376 
tubo-ovarian, 351 
Actinomycosis of Fallopian tube, 334 

of ovary, 358 
Adenocarcinoma uteri, 293 
Adenofibromyoma uteri, 264 
Adhesions, diagnosis of, 174 
Adipocere, 129 
Alcohol as a fixing agent, 95 
Alcoholism, cause of sterility, 40 
Allantoic cyst, 384. 

differentiated from ovarian 
tumors, 384 
Amenorrhcea, 34 
absolute, 34 

catching cold a cause of, 35 
causes of, general, 34 

local, 35 
changes in environment a cause 

of, 35 
debilitating disease a cause of, 34 
diseases of genital organs causing, 

35 
hypoplasia and atrophv causing, 

"35 
mental shock and anxietv causing;, 

35 
relative, 34 
Ampullar tubal pregnancy, 123 
Amyloid degeneration of uterine fib- 
roids, 268 
Anaemia causing sterility, 40 

uterine hemorrhage, 29 



Anatomy of bladder, 409 

of ovary, 338 

of peritoneum, 393 

of urethra, 409 
Angioma of vulva, 209 
Anteflexion differentiated from retro- 
versio-flexion of uterus, 202 

of uterus, 194, 202 
Anteposition of uterus, 173 
Anteversion of uterus, 193 
Apoplexia uteri, 32 

Appendicitis differentiated from sal- 
pingitis, 328 
Arterio-sclerosis of uterus, 31 
Ascites differentiated from ovarian tu- 
mors, 379 

free, 379 
Atresia of urethra, 432 

of vagina, 221 

of vulva, 204 
Atrophy of ovary, 345 
congenital, 341 

of uterine fibroids, 365 

of vulva, 211 



BALLOTTEMEXT, 107 
Bardeen C0 2 freezing microtome 
93 
Bartholinean gland, cysts of, 215 
Benign non-infectious peritonitis, 394 
Bicornate uterus, 168 

pregnant, 140 
Bladder, anatomy of 409. 

catheter hi examination of, 415 
digital examination of, 69 
distended, differentiated from 

ovarian tumors, 378 
examination of, methods of, 413 
catheter and sound, 415 
cystoscopy, 415 
inspection, 415 
Kellv-Pawlik, 421 
Xitze, 417 
palpation, 414 
percussion, 413 
segregator, 403 
urethroscopy, 415 
hemispheres of, 413 
inspection of, 415 
irritable, in pregnancy, 104 



480 



INDEX. 



Bladder, landmarks in, 412 

normal, cystoscopic appearance of, 
419 

palpation of, 413 

percussion of, 413 

physiology of, 409 

quadrants of, 413 

topography of, 411 
Blasenmole, 142 
Bozeman's specula, 72 
Broad ligament fibroids of uterus, 273 



CALCAREOUS degeneration of uter- 
ine fibroids, 266 
Cancerous degeneration of uterine 
fibroids, 268 
ulcers of cervix, 254 
Carcinoma, 214 

of cervix, 279, 283, 287, 292, 298 
cauliflower, 281 
differentiated from endo cer- 
vicitis, 254 
of corpus uteri 279, 299, 284, 287, 

293 
of Fallopian tube, 336 
infiltrating, of vaginal portion of 

cervix, 281 
of ovary, 364 
squamous-cell, of body of uterus, 

295 
syncytiale, 160 
of urethra, 436 

uteri, classification of, topograph- 
ical, 279 
recurrence in, 304 
of uterus, 279 

bimanual palpation in, 289 
cachexia in, 286 
diagnosis of, clinical, 285 
anatomical, 281 
differential, 296 
extension of, 301 
microscopic, 289 
recurrence of, 304 
etiology of, 279 
exploration of uterine cavity 

in, 289 
hemorrhage in, 285 
heredity in, 279 
leucorrhcea in, 286 
pain in, 286 
squamous-cell, 295 
symptoms, miscellaneous, in, 

286 
topographical classification, 
279 
of vagina, 231 

differentiated from decubitus 
ulcers, 233 
from syphilitic ulcers, 233 
from tuberculous ulcers, 
233 



Carcinoma of vaginal portion of cervix, 
279, 281, 286, 289, 296 
of vulva, 214 
Carcinomatous peritonitis, 395 
Caruncle, 435 
Case record, form of, 19 
Catarrh of cervix, 249 
Catarrhal endometritis, 236 
salpingitis, 319 
vaginitis, 226 
Catheter in examining bladder, 415 
Cauliflower carcinoma of cervix, 281 
Celloidin sections, 77 
Cellulitis, pelvic, 402 
acute, 403 
chronic, 404 
classification of, 402 
definition of, 402 
diagnosis of, differential, 406 
differentiated from malignant 
disease of pelvis, 407 
from paratyphlitis, 406 
from pelvic hsematoma, 
406 
peritonitis, 406 
from psoas abscess, 407 
from retro-uterine peri- 
metritis, 406 
from subserous fibroid, 
407 
exudate in, consistency of, 
405 
form of, 405 
mobility of, 405 
position of, 404 
relation of, to neighbor- 
ing organs, 405 
tenderness of, 405 
Cervical catarrh, 249 

endometritis, 249 
Cervix, carcinoma of, 279, 283, 287, 292 
298 
cauliflower, 281 
differentiated from endocer- 

vicitis, 254 
vaginal portion of, 279, 281, 
286, 289, 296 
catarrh of, 249 
ectropion of, differentiated from 

endocervicitis, 254 
erosions of, 250, 297 

classification of, 250 
diagnosis of, differential, 253 
follicular, 251 
healing of complete, 252 

incomplete, 252 
papillary, 250, 
simple, 250 
fibroids of, 261, 273 
interstitial, 298 
follicular degeneration of, 298 
hemorrhage from, 24 
laceration of, 112 



INDEX. 



481 



Cervix, mucous membrane of, e version 
of, 296 
patch on, 250 
sarcoma of, 298, 307 
technic of excising piece of, for 

microscopic examination, 289 
test excision of, 92 
tuberculosis of, 254 
ulcers of, 254 

cancerous, 254 
decubitus, 254 
svphilitic, 298 
tuberculous, 254, 297 
vaginal portion of, infiltrating car- 
cinoma of, 281 
Chorio-epithelioma malignum, 160 
diagnosis of, 161 
etiology of, 161 
following hvdatiform mole, 

146 
macroscopic appearance of, 

• 162 
of vagina, 234 
Chorion, hvdatiform degeneration of, 

142 
Chorionic villi in hydatiform mole, 146 
Chylous cysts, differentiated from ova- 
rian tumors, 383 
of mesenterv, 383 
Colpitis, 225 

emphysematous, 227 
Conception, conditions essential to, 39 
retained products of, diagnosed by 
curette, 87 
Condylomatous vaginitis, 228 
Confinement, date of, 112 
Congestion of ovary, 354 
Connective tissue tumors of ovary, 369 
Corpus luteum cysts, 355 

uteri, carcinoma of, 279, 284, 287, 
293, 299 
Currier's speculum, 75 
Cusco's speculum, 73, 74 
Cystadenoma pseudomucinosum, 362 

serosum, 364 
Cystic degeneration of ovary, 350, 375 
differentiated from ova- 
rian tumors, 375 
mole, 142 

new formations of Fallopian tube, 
337 
Cystoscope, Nitze, 417 
Cystoscopic appearance of normal blad- 
der, 419 
Cystoscopy, 415 

Cysts, allantoic, differentiated from 
ovarian tumors, 384 
of Bartholinean gland, 215 
chylous, differentiated from ova- 
rian tumors, 383 
of mesentery, 383 
corpus luteum, 355 
dermoid, of Fallopian tube, 335 



Cysts, dermoid, of ovaiy, 365 

echinococcus, differentiated from 

ovarian tumors, 378 
hvdatid, of Morgagni, 337 
of hymen, 220 
of labia minora, 216 
ovarian, 330 

degeneration of, malignant, 

389 
differentiated from peritoni- 
tis, 401 
from salpingitis, 330 
exploratory puncture and in- 
cision of, 391 
fate of, 391 
hemorrhage into, 388 
leakage of, 388 
malignant degeneration of, 

389 
rupture of, 388 
suppuration of, 389 
torsion of pedicle of, 385 
pancreatic, 382 

differentiated from ovarian 
tumors, 378, 382, 385 
from salpingitis, 330 
parovarian, 330, 371, 378, 385 
of pelvis, echinococcus, 378 
sebaceous, of vulva, 213 
simple, of ovary, 355 
tubo-ovarian, 318, 355 

of Fallopian tube, 318 
of vagina, 187, 229 

differentiated from prolapsus 
uteri, 187 
of vulva, 215 

dermoid, 214, 218. 



DECIDUA, discharge of, in ectopic 
pregnancy, 134 
of ectopic pregnancy, 301 
removal of, by curette, 89 
serotina, 146 

vera in hvdatiform mole, 146 
Decidual endometritis, 238 
Deciduoma malignum, 160 
Decubitus ulcers of cervix, 254 

of vagina, 227, 233 
Degeneration of uterine fibroids, 265 
Dermoid cysts of Fallopian tube, 335 
of ovarv, 365 
of vulva, 214, 218 
Descensus ovarii, 343 
Diagnosis of abortion, 115 
of adhesions, 174 

causing uterine displacements, 
174 
anatomical, of carcinoma of uterus, 
281 
of pregnancy, 116 
of chorio-epithelioma malignum, 
161 



31 



482 



INDEX. 



Diagnosis, clinical, of carcinoma of 
uterus, 285 
of diseases of vagina, 228 
of ectopic pregnancy, 132 
of new formations of ovary, 

373 
of salpingitis of Fallopian 
tube, 319, 325 
differential, of carcinoma of uterus, 
296 
of ectopic pregnancy, 139 
of erosions of cervix, 253 
of peritonitis, 400 
of purulent salpingitis of Fal- 
lopian tube, 328 
early, a plea for, 17 
of life and death of foetus, 111 
microscopic, of cancer of uterus, 
289 
of carcinoma of uterus, 289 
of multiparity, 112 
of sactosalpinx, 327 
of scrapings in endometritis, 249 
of uterine pregnancy, 101 
of variety of ovarian cysts, 390 
Digital examination of bladder, 69 
of internal genitals, 57 
of rectum, 66 
of vagina, 57 
Dilatation of urethra, 432 
Dilating urethral orifice, 427 
Diphtheritic ulcers of vagina, 227 
Dislocations of urethra, 433 
Divulsion, instruments of, 80 
Double uterus, 169 

vagina, 204, 224 
Dropsy of villi, 142 
Dysmenorrhcea, 36 

inflammatory diseases causing, 38 
maldevelopments causing, 37 
malpositions causing, 37, 38 
new formations causing, 38 
Dysmenorrhceal endometritis, 237 
Dyspareunia, cause of sterility, 41 



ECHINOCOCCUS cyst, differentiated 
from ovarian tumors, 378 
of pelvis, 378 
Ectopic pregnancy, 122 

active fcetal movements in, 

133 
advanced, 377 
anatomical changes in, 130 
auscultation of abdomen in, 

133 
bimanual examination in, 137 
classification of, 123 
decidua of, 301 

discharge of, in, 134 
diagnosis of, clinical, 132 
by curette, 87 
differential, 139 



Ectopic pregnancy, diagnosis of, differ- 
entiated from fibro- 
myoma uteri, 141 
from malignant disease of 

pelvis, 141 
from ovarian tumors, 140 
from pelvic exudate, 139 
hematoma and he- 
matocele, 141 
from pregnancy in a bi- 
cornate uterus, 140 
in a retroverted ute- 
rus, 138 
in a rudimentary 
horn, 140 
from uterine pregnancy 
complicated with tubal 
or ovarian swelling, 138 
etiology of, 122 
genetic reaction in, 122 
palpation of abdomen in, 133 
retrogressive changes in, 129 
suppuration in, 126 
Ectropion of cervix differentiated from 

endocervicitis, 254 
Elephantiasis of vulva, 209 
Emmet's tenaculum, 72 
Emphysematous vaginae, 227 

colpitis, 227 
Enchondroma of vulva, 213 
Endocervicitis, 249 

differentiated from carcinoma of 
cervix, 254 
from ectropion of cervix, 254 
Endometritis, 299 
acute, 235 
catarrhal, 236 

causing uterine hemorrhage, 30 
cervicalis, 249 
chronic, 236 
classification of, anatomical, 240 

clinical, 235 
decidual, 238 

diagnosed by the curette, 86 
diagnosis of scrapings in, 249 
dysmenorrhceic, 237 
exfoliative, 239 
forms of macroscopic, 240 

microscopic, 241 
fungous, 239, 240 
glandular, 242 
gonorrhceal, 237 
hemorrhagic, 236 
hypertrophic, 240 
interstitial, 247 
acute, 248 
chronic, 248 
membranous dysmenorrhcea, 239 
polypoid, 241 
postabortive, 239 
in pregnancy, 114 
pseudodiphtheritic, 241 
puerperal, 238 



INDEX. 



483 



Endometritis, senile, 239 
acute, 248 
tuberculous, 237, 300 
ulcerative, 241 
villous, 240 
Endothelioma ovarii, 371 
uteri, 304 
of vagina, 234 
Epispadias, 205, 432 

of vulva, 215 
Epithelial new formations of ovary, 359 
Erosions. See Endo cervicitis, 253 
carcinoma, 292 
of cervix, 250, 297 

classification of, 250 
diagnosis of, differential, 253 
follicular, 251 
healing of, 252 

complete, 252 
incomplete, 252 
papillary, 250 
simple, 250 
Erysipelatous vulvitis, 208 
Eversion of mucous membrane of cer- 
vix, 296 
Examining table, Schmidt, 49 
Exfoliative endometritis, 239 
Extra-uterine pregnancy, 122 
Exudates, parametric, 329, 354 

differentiated from salpingi- 
tis, 329 
paratvphlitic, 406 
pelvic, 139 

perimetric, serous, 375 
peritoneal, 398 



FALLOPIAN tube, actinomvcosis of, 
334 
anomalies in structure of, 310 
carcinoma of, 336 
changes in position of, 311 
circulatory disturbances of, 

312 
cystic new formations of, 337 
dermoid cysts of, 335 
development of, anomalies in, 

310 
examination of, methods of, 

310 
fibroma of, 335 
fibromvxoma cvstoma of the 

fimbria- of, 336 
gonorrhoea! infection of, 328 
hematosalpinx of, 318 
hydrosalpinx of, 316 
infectious granuloma of, 313 
inflammations of, 313 
lipoma of, 335 
in menstruation, 28 
myoma of, 335 
new formations of, 330, 334 
papilloma of, 334 



Fallopian tube, parasites of, 334 
polyps of, 335 
pyosalpinx of, 324 
sactosalpinx of, contents of, 
328 
diagnosis of, 327 
salpingitis of, catarrhal, 314 
chronic, 315 
diagnosis of, clinical, 
319 
classification of, 314 

purulent diagnosis of clin- 
ical, 325 
diagnosis of, differ- 
ential, 328 
tuberculous, 330 
sarcoma of, 336 
syphilis of, 334 
tumors of, 334 
tubo-ovarian cvsts of, 318 
Fibroid, birth of, 270 
Fibroids of cervix, 261, 273 
interstitial, 260 
of cervix, 298 
of uterus, 260 
intraligamentary, of uterus, 273 
intramural, of uterus, 260 
retro-uterine, 202 

differentiated from retrover- 
sio-flexion of uterus, 202 
submucous, 259, 300 
subserous, 261, 329, 407 

differentiated from pelvic cel- 
lulitis, 407 
from salpingitis, 329 
uterine, amvloid degeneration of, 
268 
atrophy of, 365 
calcareous degeneration of, 266 
cancerous degeneration of, 

268 
clinical characteristics of, 268 
degeneration of, 265 
fatty degeneration of, 267 
gangrene of, 268 
hemorrhage in, 269 
myxomatous degeneration of, 

267 
pressure and traction from, 
270 
of uterus, 256 

differentiated from chronic 
metritis, 275 
from hematocele, 277 
from hematoma, 277 
from uterine pregnane v, 
276 
submucous, 259 
subserous, 261 
suppuration of, 268 
telangiectatic, 268 
Fibroma of Fallopian tube, 335 
of ovary, 369 



484 



INDEX. 



Fibroma of urethra, 436 

of vulva, 213 
Fibromyoma, sarcomatous degenera- 
tion of, early recognition of, 309 
uteri, 141, 256 

atrophy of, 265 
changes in endometrium, 268 
characteristics of, clinical, 268 
degeneration of, 265 
amyloid, 268 
calcareous, 266 
cancerous, 268 
fatty, 267 
myxomatous, 267 
sarcomatous, 268 
diagnosis of, anatomical, 258 
clinical, 269 
differential, 275 
microscopic, 262 
differentiated from ectopic 

pregnancy, 141 
etiology of, 256 
gangrene of, 268 
hemorrhage in, 269 
histogenesis of, 257 
intraligamentary, 273 
objective signs of, 272 
palpation and adnexae and 

round ligament in, 275 
pressure and traction from, 

270 
suppuration of , 268 
telangiectatic, 268 
of vagina, 231 
Fibromvxoma cystoma of the fimbria?, 

336 " 
Fissures, congenital, of vulva, 204 
Fistulae of urethra, 436 
Fixing of specimens, 95 
Foetal heart tones, 109 
movements, 107 

active, in ectopic pregnancy, 
133 
souffle, 109 
uterus, 164 
Foetus, life and death of, diagnosis of, 

111 
Follicular degeneration of cervix, 298 
erosions, 251 

of cervix, 251 
Formalin, 95 

Fungous endometritis, 239, 240 
Furunculosis of vulva, 206 



GALL-BLADDER, distended, 383 
differentiated from ovarian tu- 
mors, 383 
Gangrene of uterine fibroids, 268 

of vulva, 205, 209 
Genital organs, normal secretions of, 45 

tract, hemorrhage from, 23 
Genitals, external, examination of, 57 



Genitals, internal, digital examination 

of, 57 
Gestation, subperitoneo-abdominal, 124 

tubo-ovarian, 126 
Glands of pregnancy, 300 
Glandular endometritis,- 242 
Gonorrhceal endometritis, 237 

infection of Fallopian tube, 328 

peritonitis, 394 
Graafian follicles, 339 
Granuloma, infectious, of Fallopian 

tube, 313 
Granulomata, infectious, of ovary, 356 



HEMATOCELE differentiated from 
fibroids of uterus, 277 
pelvic, 406 
retro-uterine, 202, 376 

differentiated from peritoni- 
tis, 400 
Haematocolpos from atresia vaginae, 

222, 223 
Haematoma, 125, 277 

differentiated from fibroids of ute- 
rus, 277 
intraligamentary, 376 
of the ovary, 346, 347 
pelvic, 141, 406 

differentiated from pelvic cel- 
lulitis, 406 
retro-uterine, 202 
of vulva, 209 
Haematometra from atresia vaginae, 

222 
Haemato salpinx, 318 

from atresia vaginae, 222 
of Fallopian tube, 318 
Haematotrachelos from atresia vaginae, 

222 
Hardening and embedding in celloidin, 
95 
in paraffin, 96 
Hemorrhage in carcinoma of uterus, 285 
caused by the curette, 88 

by sound, 85 
from cervix, 28 
during pregnancy, 113 
in fibromyoma uteri, 269 
from genital tract, 23 
in uterine fibroids, 269 
into ovarian cysts, 388 
intraperitoneal, 135 
uterine, anaemia a cause of, 29 
endometritis causing, 30 
local causes of, 29 
passive congestion causing, 29 
plethora causing, 29 
purpuric conditions causing, 

29 
specific infectious diseases 

causing, 29 
subinvolution causing, 29 



INDEX. 



485 



Hemorrhage, uterine, systemic causes 
of, 29 
from vagina, 24 
from vulva, 24 
Hemorrhagic endometritis, 236 

metritis of menopause, 32 
Hermaphroditism, 205 
Hernia of ovary, 344 

of uterus, 203 
Hvdatid cvsts of Morgagni, 337 

mole, "142 
Hydatids, uterine, 142 
Hvdatiform degeneration of chorion, 
142 
mole, chorio-epithelioma malig- 
num following, 146 
chorionic villi in, 146 
decidua serotina in, 146 

vera in, 146 
degeneration of, malignant, 

150 
diagnosis of, 154 
examination of, microscopic, 

146 
history of, 142 

syncytioma malignum follow- 
ing, 151 
Hydronephrosis, 384 

differentiated from ovarian tu- 
mors, 384 
Hydrops tubse profluens, 317 
Hydrosalpinx, 316 

of Fallopian tube, 316 
Hvmen, 220 

cysts of, 220 
rupture of, in labor, 112 
Hypertrophic endometritis, 240 
Hypertrophy, congenital, of ovary, 342 
of ovarv, 345 
of vulva, 209 
Hypoplasia and atrophy causing amen- 
orrhea, 35 
Hypospadias, 205, 432 

of vulva, 205 
Hvsterocele, 203 



TXFANTILE vulva, 204 
A Infectious granulomat a of Fallopian 
tube, 313 
granulomata of ovary, 356 
Infiltrating carcinoma of vaginal por- 
tion of cervix, 281 
Inflammations of Fallopian tube, 313 
of ovary, 348 
of urethra, 433 
Inflammatory diseases causing dys- 
menorrhcea, 38 
sterility, 43 
Infundibular tubal pregnancy, 1 29 
Interstitial endometritis, 247 
acute, 248 
chronic, 248 



Interstitial fibroid of cervix, 298 
fibroids of uterus, 260 
tubal pregnancy, 129 
Interureteric ligament, 412 
Intraligamentary development of ova- 
rian tumors, 384 
fibroids of uterus, 273 
hsematoma, 376 
Intramural fibroids of uterus, 260 
Intraperitoneal hemorrhage, 135 
Inversion of the uterus, 187 

differentiated from partially 
divided uterus with a 
depression in the fun- 
dus, 192 
from pedunculated fib- 
roid or polyp lying 
within the vagina, 192 
from prolapsus uteri, 192 
from submucous fibroid 
lying within the cavity 
of the uterus, 192 
from submucous fibroid 
with partial inversion, 
192 



KELLY-PATVXIK method of cvstos- 
copy, 421 
Knee-chest position, 60 
Kraurosis vulvae, 211 



LABIA minora, cysts of, 216 
Labor, spurious, 134 
Laceration of cervix, 112 
Lateroposition of uterus, 174 
Leprosy of ovary, 358 
Leucorrhcea, 45 

in cancer of uterus, 286 
in infants, 45 
in old women, 46 
in pregnancy, 106 
in sexual maturity, 46 
in virgins, 45 
Lipoma of Fallopian tube, 335 

of vulva, 213 
Lithopedion, 129 
Lithotomy position, 60 
Liver, tumors of, 383 

differentiated from ovarian 
tumors, 383 



1TALDEVELOPMENTS causing dys- 
ul menorrhcea, 37 

sterility, 41 

of ovary, 341 

of vagina, 221 
Malformations causing sterility, 41 

congenital, of urethra, 432 

of urethra, acquired, 432 



486 



INDEX. 



Malformations of uterus, 163 
accessorius, 169 
bicornis, 168 

unicellis, 170 
deficiens, 163 
didelphys (uterus duplex, 

uterus separatus), 169 
fcetalis, 164 
membranaceous, 163 
rudimentarius, 163 . 
septus (bilocularis), 168 

duplex, 167 
unicornis, 166 
of vagina, 221 
Malignant growth diagnosed by the cu- 
rette, 87 
Malpositions causing dysmenorrhea, 38 
sterility, 42 
of uterus, 171 

anteflexion, 194 
anteposition, 173 
ante version, 193 
elevatio-uteri, 176 
hernia, 203 
inversion, 187 
lateroposition, 174 
pathological fixation, 171 

mobility, 171 
primary descent, 181 
prolapsus, 178 

uteri with atresia, 186 
retroposition, 173 
' retroversio-flexion, 195 
secondary descent, 181 
torsion, 177 
Mammary glands, changes of, in preg- 
nancy, 104, 113 
changes in, in tubal preg- 
nancy, 133 
Marriage of near relatives a cause of 

sterility, 40 
Membranaceous uterus, 163 
Menopause, 44 

clinical manifestations of, 44 
effect of climate on, 44 
heredity on, 44 
race on, 44 
social state on, 44 
hemorrhagic, metritis of, 32 
Menorrhagia, 28 
Menses, retention of, 35 
Menstruation, 24 
anatomy of, 26 
cessation of, 101 
effects of ovariotomy on, 35 
Fallopian tube in, 28 
menstrual molimena, 36 
pain during, 36 
physiological absence of, 34 
in tubal pregnancy, 133 
Mesentery, chylous cysts of, 383 
Metastasis in carcinoma uteri, 303 



Metritis, chronic, 255, 275 

differentiated from fibroids of 
uterus, 275 
coli, 298 

hemorrhagic, of menopause, 32 
Metrorrhagia, 28 
Microtome, Bardeen C0 2 freezing, 93 

student, 96 
Miscarriages, number of children and, 

22 
Mole, cystic, 142 

formation in tubal pregnancy, 128 
hydatid, 142 

hydatiform, chorio-epithelioma 
malignum following, 146 
chorionic villi in, 146 
decidua vera in, 146 
history of, 142 
ulcus of vulva, 208 
Morgagni, hydatid cysts of, 337 
Morning sickness, 103 

in tubal pregnancy, 133 
Mucous patch on cervix, 250 

polyps, 301 
Multiparity, diagnosis of, 112 
Mummification, 129 
Myoma of Fallopian tube, 335 
ovarii, 370 
uteri, 256 
Myxoma chorii, 142 
Myxomatous degeneration of uterine 
fibroids, 267 



NARCOSIS, examination under, 66 
Nervous phenomena in pregnancv 
104 
in tubal pregnancy, 133 
Neuroma of vulva, 213 
Nitze cystoscope, 417 



OBESITY, 384 
cause of sterility, 40 
(Edema of vulva, 209 
Omentum, fatty tumors of, 283, 378 
Oophoritis, 348 

Ovarian cyst, degeneration of, malig- 
nant, 389 
diagnosis of variety of, 390 
differentiated from peritoni- 
tis, 401 
from salpingitis, 330 
exploratory puncture and in- 
cision of, 391 
fate of, 391 
hemorrhage in, 388 
leakage of, 388 
malignant degeneration of, 

389 
rupture of, 388 
suppuration of, 389 






INDEX. 



487 



Ovarian cyst, torsion of pedicle of, 385 
tumors, 140, 358 
bilateral, 384 

complicating pregnancy, 390 
development of, intraliga- 

mentary, 384 
differentiated from allantoic 
cysts, 384 
from ascites, 379 
from chylous cysts, 383 
from cystic degeneration 

of ovaries, 375 
from distended bladder, 

378 
from distended gall-blad- 
der, 383 
from echinococcus cyst, 

378 
from ectopic pregnancv, 

140 
from fatty tumors, 383 
from hydronephrosis, 384 
from pancreatic cvsts, 

382 
from parovarian cysts, 

378, 385 
from phantom tumors. 

378 
from splenic tumors, 383 
from tumors of liver, 383 
fate of, 391 

intraligamentarv, develop- 
ment of, 384 
Ovariotomy, effect on menstruation, 36 
Ovaritis, 348 
acute, 348 
chronic, 349, 352 
diagnosis of, clinical, 352 
differentiated from congestion of 
ovary 354 
from new-growth of ovarv, 

354 
from parametric exudates, 354 
from perityphlitis, 354 
salpingitis, 354 
tuberculous, 356 
Ovary, abscess of, 351, 353 
acute, 351 
chronic, 351 
absence of, 341 
actinomycosis of, 358 
anatomy of, 338 
atrophy of, 345 

congenital, 341 
carcinoma of, 314 
changes in position of, 342 
circulatory disturbances of, 346 
congestion of, 354 

differentiated from ovaritis, 
354 
corpus luteum cysts of, 355 
cystic degeneration of, 350, 375 



Ovary, cystic degeneration of, differen- 
tiated from ovarian tumors, 375 
cysts of, dermoid, 365 

simple, 355 
degeneration of, cystic, 350 
development of, anomalies in, 341 
endothelioma of, 371 
examination of, methods of, 340 
fibroma of, 369 
foreign bodies in, 346 
granulomata of, infectious, 356 
hsematoma of, 346 
hernia of, 344 
histology of, 338 
hypertrophy of, 345 

congenital, 342 
inflammation of, 348 
leprosy of, 358 
maldevelopments of, 341 
myoma of, 370 
new formations of, 358 

clinical diagnosis of, 373 
epithelial, 359 

growths of, 354 

differentiated from ova- 
ritis, 354 
parasites of, 346 
sarcoma of, 370 
supernumerary, 341 
syphilis of, 357 
torsion of pedicle of, 385 
tuberculosis of, 356 
tumors of, 358 

adherent, 385 

connective tissue, 369 



PANCREATIC cysts, 382 
differentiated from ovarian 
tumors, 382 
Papillary erosions, 250 
Papilloma of Fallopian tube, 334 
Paraffin sections, 98 
Parametric exudates, 329, 354, 376 

differentiated from ovaritis, 
354 
from salpingitis, 329 
Parametritis. See Pelvic cellulitis, 402 
acute, 403 
chronic, 404 
retro-uterine, 406 
Parasites of Fallopian tube, 334 

and foreign bodies of the ovarv, 
346 
Paratyphlitic exudate, 406 
Paratyphlitis differentiated from pel- 
vic cellulitis, 406 
Paravaginitis, 229 
Parovarian cysts, 330, 371, 378, 385 

differentiated from ovarian 

tumors, 378, 385 

from salpingitis, 330 



488 



INDEX. 



Pawlik method of cystoscopy, 421 
Plan's speculum, 74 
Pedunculated fibroids and polyps ly- 
> ing within the vagina, 192 
Pelvic cellulitis, 402 
acute, 403 
chronic, 404 
classification of, 402 
definition of, 402 
diagnosis of, differential, 406 
differentiated from malignant 
disease of pelvis, 407 
from paratyphlitis, 406 
from pelvic hematoma, 
406 
peritonitis, 406 
from psoas abscess, 407 
from retro-uterine peri- 
metritis, 406 
from subserous fibroid, 
407 
exudate in, consistency of, 
405 
form of, 405 
mobility of, 405 
position of, 404 
relation of, to neighbor- 
ing organs, 405 
tenderness of, 405 
exudate, 139 

differentiated from ectopic 
pregnancy, 139 
hematocele differentiated from 

etopic pregnancy, 141 
hsematoma, 406 

differentiated from pelvic cel- 
lulitis, 406 
and hematocele, 141 
inflammation, acute and subacute, 
a contraindication to cu- 
rettage, 88 
caused by the sound, 85 
peritonitis, 395, 406 
acute, 397 

adhesions in, peritoneal, 398 
chronic, 397 
definition of, 395 
diagnosis of, clinical, 399 

differential, 400 
differentiated from pelvic cel- 
lulitis, 406 
etiology of, 397 
exudates in, peritoneal, 398 
Pelvimetry, 70 

Pelvis, cysts of, echinococcus, 378 
malignant disease of, 141, 407 

differentiated from ec- 
topic pregnancy, 
141 
from pelvic celluli- 
tis, 407 
Pericecal abscess, 376 
Perimetric exudates, serous, 375 



Perimetric exudates, retro-uterine, dif- 
ferentiated from pelvic cellulitis, 406. 
Perineum, rupture of, in labor, 112 
Periovaritis, tuberculous, 356 
Peritoneal adhesions, 398 

exudates, 398 
Peritoneum, anatomy of, 393 
Peritonitis, 393 

benign, non-infectious, 394 
carcinomatous, 395 
diagnosis of, differential, 400 
differentiated from ovarian cyst, 
401 
from retroflexed gravid ute- 
rus, 400 
from retro-uterine hemato- 
cele, 400 
general, 393 
gonorrhceal, 394 
pelvic, 395, 406 
acute, 397 

adhesions in, peritoneal, 398 
chronic, 397 
definition of, 395 
diagnosis of, clinical, 399 

differential, 400 
differentiated from pelvic 

cellulitis, 406 
etiology of, 397 
exudates in, peritoneal, 398 
putrid, saprophytic, 394 
retro-uterine, 406 
septic, 394 
tuberculous, 395 
Perityphlitis, 354 

differentiated from ovaritis, 354 
Placenta previa, 114 

premature detachment of, 115 
Placental souffle, 109 

tissue, retained, 300 
Plethora causing uterine hemorrhage, 

29 
Polypoid endometritis, 241 
Polyps of Fallopian tube, 335 
Postabortive endometritis, 239 
Pozzi's tenaculum forceps, 76 
Pregnancy, auscultation of abdomen in, 
109 
in bicornate uterus, 140 
in a bicornate uterus differen- 
tiated from ectopic pregnancy, 
140 
changes in mammary glands in, 

104, 113 
complicated by ovarian tumors, 

390 
complicating tubal or ovarian 

swelling, 139 
contraindications to curettage 

after, 88 
diagnosis of, anatomical, 116 
discoloration of vagina in, 104 



INDEX. 



489 



Pregnancy, ectopic, 122 

active fcetal movements in, 

133 
advanced, 377 
anatomical changes in, 130 
auscultation of abdomen in, 

133 
bimanual examination in, 137 
classification of, 123 
decidua of, 301 

discharge of, in, 134 
diagnosis of, clinical, 132 
by curette, 87 
differential, 139 
differentiated from fibromy- 
oma uteri, 141 
from malignant disease of 

pelvis, 141 
from ovarian tumors, 140 
from pelvic exudate, 139 
hematoma and hse- 
matocele, 141 
from pregnane}* in a bi- 
cornate uterus, 140 
in aretroverted ute- 
rus, 138 _ 
in a rudimentary 
horn, 140 
from uterine pregnancy 
complicated with tu- 
bal or ovarian swelling, 
138 
discoloration of vagina in, 133 
etiology of, 122 
genetic reaction in, 122 
palpation of abdomen in, 133 
retrogressive changes in, 129 
suppuration in, 126 
endometritis in, 114 
extra-uterine, 122 
glands of, 300 
hemorrhage during, 113 
interstitial tubal, 129 
irritable bladder in, 104 
leucorrhcea in, 106 
multiple diagnosis of, 113 
nervous phenomena in, 104 
ovarian tumors complicating, 390 
position of uterus in, 110 
in retroverted uterus, 138, 139 
retroverted uterus complicating, 

138 
in a retroverted uterus differen- 
tiated from ectopic pregnancy, 
138 
in rudimentaiy horn, 140 - 
in a rudimentary horn differen- 
tiated from ectopic pregnancv, 
140 
tubal, 122 

abscess formation in, 128 
ampullar, 123 



Pregnancv, tubal, changes in mammarv 
glands in, 133 
infundibular, 129 
menstruation in, 133 
mole formation in, 128 
morning sickness in, 133 
nervous phenomena in, 133 
pain in, 133 
uterine, 276 

complicated with tubal and 

ovarian swellings, 138 
diagnosis of, 101 
differentiated from fibroids of 
uterus, 276 
Prolapse of urethra, 433 
of uterus, 178, 192 
of vagina, 180 
Prolapsus uteri, 192 

w T ith atresia, 186 
differentiated from inversion 
of uterus, 186 
from cyst of vagina, 187 
Pruritus, 217 

Pseudodiphtheritic endometritis, 241 
Psoas abscess, 407 

differentiated from pelvic cel- 
lulitis, 407 
Puerperal endometritis, 238 
ulcers of vagina, 226 
vaginitis, 226 
vulvitis, 208 
Purpuric conditions causing uterine 

hemorrhage, 29 
Purulent salpingitis. 321, 322 
Pus tube, 324 

Putrid saprophvtic peritonitis, 394 
Pyosalpinx, 324 



Q 



UADRAXTS of bladder, 413 



RECTUM, abdomino-rectal, 68 
digital examination of, 66 
simple rectal touch, 66 
traction on uterus in rectal exam- 
inations, 69 
Retroflexed pregnant uterus, 376 
Retroposition of uterus, 173 
Retro-uterine fibroids, 202 

differentiated from retrover- 
sio-flexion of uterus, 203 
hematocele, 376 
hsematoma and hematocele, 202 
parametritis, 406 
perimetritis differentiated from 

pelvic cellulitis, 406 
peritonitis, 406 
Retro versio-flexion of uterus, 195 

of uterus differentiated from 
anteflexion, 202 



490 



INDEX. 



Retroversio-flexion of uterus, from re- 
tro-uterine fibroids, 203 
from swellings of tubes 
and ovaries, 202 
Retroverted uterus complicating preg- 
nancy, 138 
Rodent ulcers of vulva, 217 
Rudimentary uterus, 163 



SACTOSALPINX, contents of, 328 
diagnosis of, 327 
of Fallopian tube, contents of, 328 

diagnosis of, 327 
purulenta, 324 
Salivation, 103 
Salpingitis, 354 
catarrhal, 319 

acute, 315, 319 
chronic, 315, 319 
of Fallopian tube, 314 
chronic, 315 
classification of, 314 
differentiated from appendicitis, 
328 
from new formation of tubes, 

330 
from ovarian cysts, 330 
from ovarian tumors, 354 
from parametric exudates, 

329 
from parovarian cysts, 330 
from subserous fibroids, 329 
of Fallopian tube, diagnosis of, 

clinical, 319 
isthmica nodosa, 316 
puerperal, 321, 322 
purulent, of Fallopian tube, diag- 
nosis of, clin- 
ical, 325 
differential, 328 
tuberculous, 330 

of Fallopian tube, 330 
Sarcoma of body of uterus, 307 
of cervix, 298, 307 
of uterus, 307 

vaginal portion, 306 
of Fallopian tube, 336 
ovarii, 370 
of urethra, 436 
of uterus, 306, 307 

diagnosis of, anatomical, 306 
clinical, 308 
microscopic, 307 
etiology of, 306 
of vagina, 231 
of vulva, 215 
Sarcoma-chorio-cellulare, 160 
Sarcomatous degeneration of a fibro- 

myoma, early recognition of, 309 
Sebaceous cysts of vulva, 213 
Secondary descent and prolapse of 
uterus, 181 



Segregator, 430 

Senile endometritis, 32, 239 

acute, 248 
Septic peritonitis, 394 
Sexual excess a cause of sterility, 41 
incompatibility a cause of sterility, 

41 
instinct, its influence upon steril- 
ity, 40 
Simon's speculum, 73 
Sims' duck-bill speculum, 71 
position, 63 
vaginal depressor, 71 
Soft chancre, 208 

Sound in examining urethra and blad- 
der, 415 
use of, in uterine fibroids, 273 
Specimens, mounting of, method of, 97 

staining of, method of, 97 
Speculum, urethral, introduction of, 
429 
vaginal, 71 

Bozeman's, 72 
Curco's, 73, 74 
Currier's, 75 
Pean's, 74 
Simon's. 73 
Sims' duck-bill, 71 
tubular, 74, 75 
Spiegelberg's sign, 303 
Splenic tumors, 383 
s Spurious labor, 134 
i Squamous-cell carcinoma of uterus, 295 
! Sterility, 38 

alcoholism a cause of, 40 
anaemia a cause of, 40 
causes of, 40 

dyspareunia a cause of, 41 
inflammatory diseases causing, 43 
influence of sexual instinct on, 40 
maldevelopments causing, 41 
malformations causing, 41 
malpositions causing, 42 
new formations causing, 43 
obesity a cause of, 40 
primary, 39 
secondary, 39 
sexual excess a cause of, 41 

incompatibility a cause of, 41 
traumatisms causing, 42 
Streptococcus infection of Fallopian 

tube, 328 
Stria? gravidarum, 113 
Stricture of urethra, 432 
Subinvolution causing uterine hemor- 
rhage, 29 
Submucous fibroids, 259 

partial inversion, 192 
of uterus, 259 
and interstitial fibroids, 300 
polyps and fibroids in cavity of 
uterus, 192 



INDEX. 



491 



Subperitoneal fibroids of uterus, 261 
Subperitoneo-abdominal gestation, 124 
Subserous fibroid, 261, 329 
fibroids of uterus, 261 
Supernumerary ovary, 341 
Syncytioma malignum following Iry- 
datiform mole, 151 
of vagina, 234 
Syphilis of Fallopian tube, 334 

of ovarv, 357 
Syphilitic ulcers, 216, 217 
of cervix, 298 
differentiated from carcinoma 

of vagina, 233 
of vagina, 227 
vulvitis, 208 



TELANGIECTATIC fibroids of ute- 
rus, 268 
Tents, 80 

sea-tangle, 80 
sponge, 80 
tupelo, 80 
Torsion of pedicle of ovarian cysts, 385 

of uterus, 177 
Traumatisms causing sterility, 42 
Trigone, 412 
Tubal abortion, 127 
pregnancy, 122 

abscess formation in, 128 
ampullar, 123 
infundibular, 129 
interstitial, 129 
menstruation in, 133 
mole formation in, 128 
morning sickness in, 133 
nervous phenomena in, 133 
pain in, 133 
Tuberculosis of cervix, 254 

of ovary, 356 
Tuberculous endometritis, 356 
ovaritis, 356 
periovaritis, 356 
salpingitis, 330 

ulcers differentiated from carcino- 
ma of vagina, 233 
of cervix, 254, 297 
of vagina, 227 
of vulva, 217 
vaginitis, 227, 233 
vulvitis, 208 
Tubo-cvsts, 318, 355 
Tubo-disease, 328 
Tubo-ovarian abscess, 351 
Tubo-peritoneal gestation, 126 
Tumors, adherent, of ovary, 385 

connective tissue, of ovary, 369 
of Fallopian tube, 334 
fatty, differentiated from ovarian 
tumors, 383 
of omentum, 283 
of liver, 383 



Tumors of liver differentiated from 
ovarian tumors, 383 
of omentum, 378 
ovarian, 140, 358 
bilateral, 384 

complicating pregnancy, 390 
development of, intraliga- 

mentary, 384 
differentiated from allantoic 
cysts, 384 
from ascites, 379 
from chylous cysts, 383 
from cystic degeneration 

of ovaries, 375 
from distended bladder. 

378 _ 
from distended gall-blad- 
der, 383 
from echinococcus cyst, 

378 
from ectopic pregnancv, 

140 
from fatty tumors, 383 
from hydronephrosis, 384 
from pancreatic cvsts, 

382 
from parovarian cvsts, 

378, 385 
from phantom tumors, 

378 
from splenic tumors, 383 
from tumors of liver, 383 
fate of, 391 

intralisjamentarvdevelopment 
of, 384 
of ovary, 358 

adherent, 385 
phantom, of abdominal wall, 378 
differentiated from ovarian 
tumors, 378 
splenic, 383 

differentiated from ovarian 
tumors, 383 
of urethra, 435 
of vulva, 213 



ULCERATIVE endometritis, 241 
vaginitis, 226 
Ulcers, cancerous, of cervix, 254 
of cervix, 254 

tuberculous, 254, 297 
decubitus, 254 
S3T)hilitic, 216, 217 
of cervix, 298 
differentiated from carcinoma 

of vagina, 233 
of vagina, 227 
tuberculous, 254 

differentiated from carcinoma 
of vagina, 233 
of vagina, decubitus, 227-233 
diphtheritic, 227 



492 



INDEX. 



Ulcers of vagina, puerperal, 226 
tuberculous, 227 
of vulva, 217 
rodent, 217 
tuberculous, 217 
Ulcus moll.; of vulva, 208 
Unicornate uterus, 166 
Urachus cysts, 384 
Ureteral orifices, 412 
Urethra, absence of, 432 
anatomy of 409, 
atresia of, 432 
carcinoma of, 436 
dilatation of, 432 
dislocation of, 433 
displacements of, 432 
examination of, methods of, 413 
catheter and sound, 415 
cystoscopy, 415 
inspection, 415 
Kelly-Pawlik, 421 
Nitze, 417 
palpation, 414 
percussion, 413 
segregator, 430 
urethroscopy, 415 
fibroma of, 436 
fistulse of, 436 
foreign bodies in, 437 
inflammation of, 433 
inspection of, 415 
malformations of, 432 
acquired, 432 
congenital, 432 
new-growths of, 435 
palpation of, 413 

partial or complete absence of, 432 
physiology of, 409 
prolapse of, 433 
sarcoma of, 436 
stricture of, 432 
tumors of, 435 
Urethral caruncle, 211 
fistulae, 436 
folds, 412 

speculum, introduction of, 429 
Urethritis, 433 
acute, 434 
chronic, 435 
Urethroscopy, 415 
Uterine cavity exposed, 98 

contractions, intermittent, 108 
curette, 86 

contraindications for, 88 
dangers involved in, 88 
in diagnosis, 86 
dilators, 78 

Ellinger's 79 
Goodell's, 79 
Hegar's, 78 
displacements, diagnosis of adhe- 
sions causing, 174 



Uterine fibroids, 375 

amyloid degeneration of, 268 

atrophy of, 365 

calcareous degeneration of, 

266 
cancerous degeneration of, 

268 
clinical characteristics of, 268 
degeneration of, 265 
fatty degeneration of, 267 
gangrene of, 268 
hemorrhage in, 269 
myxomatous degeneration of, 

267 
pressure and traction from, 
270 
hemorrhage, anaemia a cause of, 
29 
endometritis causing, 30 
passive congestion causing, 29 
plethora causing, 29 
purpuric conditions causing, 

29 
specific infectious diseases 

causing, 29 
subinvolution causing, 29 
hydatids, 142 
pregnancy, 276 

complicated with a tubal and 

ovarian swelling, 138 
diagnosis of, 101 
differentiated from fibroids of 
uterus, 276 
segment, lower, softening and com- 
pressibility in pregnancy, 106 
sound, 83 

dangers involved in the use 

of, 84 
indications for the use of, 83 
preliminary procedures, 83 
tissue, removal of, for diagnostic 
purposes, 91 
Uterus, absence of, 163 
accessorv, 169 
anteflexion of, 194, 202 
anteposition of, 173 
ante version of, 193 
arterio-sclerosis of, 31 
body of, sarcoma of, 307 

squamous-cell carcinoma of, 
295 
broad ligament fibroids of, 273 
cancer of, leucorrhcea in, 286 
carcinoma of, 279 

bimanual palpation in, 289 
cachexia in, 286 
diagnosis of, anatomical, 281 
clinical, 285 
differential, 296 
extension of, 301 
microscopic, 289 
recurrence of, 304 



INDEX. 



493 



Uterus carcinoma of, etiology of, 279 
exploration of uterine cavity 

in, 289 
extension of, 301 
hemorrhage in, 285 
heredity in, 279 
leucorrhcea in, 286 
pain in, 286 
squamous-cell, 295 
symptoms, miscellaneous, in, 
" 286 

topographical classification, 
279 
cervix of, sarcoma of, 307 

vaginal portion, sarcoma of, 
306 
descent of, 178 
double, 169 
elevation of, 176 
endothelioma of, 304 
fibroids of, 256 

differentiated from chronic 
metritis, 275 
from hsematocele, 277 
from haematoma, 277 
from uterine pregnancv, 
276 
interstitial, 260 
intraligamentary, 273 
intramural, 260 
submucous, 259 
subperitoneal, 261 
subserous, 261 
suppuration of, 268 
telangiectatic, 268 
fixation of, pathological, 171 
hemorrhage from, 28 
hernia of, 203 

inspection of, after removal, 99 
inversion of, 187 

differentiated from prolapsus 
uteri, 186 
lateroposition of, 174 
malformation of, 163 
malpositions of, 171 
membranes expelled from, 120 
membranous, 163 
mobility of, pathological, 171 
perforation of, by curette, 88 

by sound, 85 
position of, in pregnancy, 110 
primary descent and prolapse of, 

181 
prolapse of, 178 
retronexed gravid, differentiated 

from peritonitis, 400 
retroposition of, 173 
retroversio-flexion of, 195 

differentiated from anteflex- 
ion, 202 
from retro-uterine fibroid, 
203 



Uterus, retroversio-flexion differen- 
tiated from swellings of tubes 
and ovaries, 202 
retroverted, complicating preg- 
nancy, 138 
rudiment arjr, 163 
sarcoma of, 306, 307 

diagnosis of, anatomical, 306 
clinical, 308 
microscopic, 307 
etiology of, 306 
test curettage of, 92 
torsion of, 177 



VAGINA, absence of, 221 
atresia of, 221 
carcinoma of, 231 
chorio-epithelioma malignum of, 

234 
cysts of, 187, 229 

differentiated from prolapsus 
uteri, 187 
decubitus ulcers of, 227, 233 
descent of, 180 
diagnosis, clinical, of diseases of, 

228 
digital examination of, 57 
discoloration of, in ectopic preg- 
nancy, 133 

in pregnane}', 104 
displacement of, 179 
double, 204, 224 
emphysematous, 227 
endothelioma of, 234 
fibroma of, 231 
hpematocolpos of, 222 
hsematometra of, 222 
hematosalpinx of, 222 
hemorrhage from, 24 
laceration of, in labor, 113 
maldevelopments of, 221 
malformations of, 221 
new formations of, 229 
prolapse of, 180 
sarcoma of, 231 
stenosis of, 221 
synevtioma of, 234 
ulcers of, decubitus, 227-233 

diphtheritic, 227 

puerperal, 226 

syphilitic, 227 

tuberculous, 227 
Vaginal examination, choice of hand in 
59 

combined, 59 
Vaginitis, 225 

catarrhal, 226 
condylomatous, 228 
puerperal, 226 
tuberculous, 227, 233 
ulcerative, 226 



494 



INDEX. 



Villi, dropsy of, 142 
Villous endometritis, 240 
Vulva, absence of, 204 

angioma of, 209 

atresia of, 204 

atrophy of, 211 

cancer of, 214 

carcinoma of, 214 

circulatory disturbances of, 208 

condylomata acuminata of, 209 

congenital fissures of, 204 

cysts of, 215 

dermoid, 214 

development of, anomalies in, 204 

double, 204 

elephantiasis of, 209 

en chondroma of, 213 

epispadias of, 215 

fibroma of, 213 

fissures of, congenital, 204 

furunculosis of, 206 

gangrene of, 205, 209 

hematoma of, 209 

hemorrhage from, 24 



Vulva, hypertrophy of, 219 
hypospadias of, 205 
infantile types of, 204 
lipoma of, 213 
neuroma of, 213 
new formations of, 213 
oedema of, 209 
sarcoma of, 215 
sebaceous cysts of, 213 
tumors of, 213 
ulcers of, 217 
rodent, 217 
tuberculous, 217 
ulcus molle of, 208 

Vulvitis, 206 

erysipelatous, 208 
furunculosis, 206 
puerperal, 208 
syphilitic, 208 
tuberculous, 208 



'ENKER'S fluid, 95 




































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